Clinical heterogeneity of bronchiectasis exacerbations: a multicentre real-world study

Background and aim Exacerbations are critical events in the natural history of bronchiectasis. While an international definition has been proposed for clinical trials by an EMBARC/BRR task force, the clinical presentation of exacerbations varies considerably among patients. The aim of our study was to assess the clinical heterogeneity of signs and symptoms of bronchiectasis exacerbations in a real-world setting. Methods This was a multicentre cross-sectional study involving nine bronchiectasis centres in Italy. Consecutive adults with bronchiectasis reported symptoms during stable-state and during typical exacerbations over the past 2 years. Symptom frequency, their impact on daily life, and concordance with the 2017 EMBARC/BRR definition were assessed overall and by comorbidity/infection subgroups. Results We enrolled 367 patients (79% female; median age 65 years). During exacerbations, cough (87%), increased sputum volume (81%), and purulence (77%) predominated and clustered with fatigue (72%) and exertional dyspnoea (64%). Patients ranked cough and sputum changes as highest impact. Overall, 85% of typical exacerbations met EMBARC/BRR criteria; exacerbation events that were not concordant with EMBARC/BRR criteria were more frequent in patients with NTM-PD (p=0.004). Patients with asthma/COPD as comorbidity reported more dyspnoea and wheezing, patients with chronic P. aeruginosa infection more frequently reported haemoptysis and nocturnal dyspnoea. Conclusions Exacerbations present with distinct symptom patterns across subgroups, and about one in seven typical patient reported events do not meet consensus criteria, underscoring the need for more sensitive patient-centred definitions.