NICE vs BTS: Management of Bronchiectasis (2025)

This guide provides a comparative summary of the National Institute for Health and Care Excellence (NICE) Clinical Guideline [NG.117] (published 2018, last updated December 2023) and the British Thoracic Society (BTS) Guideline for Bronchiectasis in Adults (published 2019, updated 2023). It is designed to help UK clinicians understand the nuances between these two key documents to inform daily practice.

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Diagnosis and Initial Assessment

Both guidelines agree on the central role of high-resolution computed tomography (HRCT) for confirming a diagnosis of bronchiectasis. However, their approaches to the initial assessment differ in emphasis and detail.

NICE Approach

NICE provides a structured, stepwise pathway focused on confirming diagnosis, identifying cause, and assessing severity.

• Diagnosis: HRCT is the first-line investigation for adults with suspected bronchiectasis.
• Investigating Cause: Recommends a core set of tests: full blood count, immunoglobulin levels (IgG, IgA, IgM), and Aspergillus fumigatus-specific IgE (or skin prick test).
• Severity Assessment: Suggests using the Bronchiectasis Severity Index (BSI) or E-FACED score to stratify risk and guide management intensity.

BTS Approach

The BTS guideline offers a more extensive and detailed investigation panel, aiming to identify a wider range of potentially treatable underlying causes.

• Diagnosis: Concurs that HRCT is the gold standard.
• Investigating Cause: Recommends a two-tiered approach:
  • First-line: Includes all NICE-recommended tests plus sputum culture (including for non-tuberculous mycobacteria), autoantibody screen, and protein electrophoresis.
  • Second-line (for specific indications): Tests for alpha-1-antitrypsin deficiency, cystic fibrosis, primary ciliary dyskinesia, and bronchoscopy.
• Severity Assessment: Also endorses the use of BSI/E-FACED but places stronger emphasis on baseline spirometry and quality of life measures like the QOL-B.

Key Difference & Practical Takeaway

Scope of Aetiological Investigation: BTS recommends a broader initial workup. For a comprehensive assessment, particularly in complex or severe cases, the BTS tiered approach is more detailed. NICE offers a pragmatic, core set of tests suitable for most initial presentations in primary and secondary care.

Treatment and Management

Both guidelines cover the main pillars of bronchiectasis management: airway clearance, exacerbation management, and long-term therapy. Key differences exist in the recommendations for long-term antibiotics.

Airway Clearance Techniques (ACT)

Agreement: Both NICE and BTS strongly recommend that all patients should be taught ACTs (e.g., active cycle of breathing techniques, positive expiratory pressure devices) and should perform them at least once daily.

Management of Exacerbations

Agreement: Both guidelines recommend prompt antibiotic treatment for exacerbations, guided by sputum culture and sensitivity where possible. Antibiotic choice should follow local formularies based on likely pathogens.

Long-term Antibiotics

This is the area of most significant divergence.

• NICE: Recommends considering long-term antibiotics for patients who have 3 or more exacerbations per year that require antibiotics. The choice of antibiotic (oral or nebulised) should be based on sputum microbiology.
• BTS: Is more conservative. It recommends considering long-term antibiotics only after other factors have been optimised (ACTs, comorbidities) and for patients with frequent (>3/year) or significant exacerbations. It provides a more nuanced discussion on the risks of antibiotic resistance and places a stronger emphasis on nebulised antibiotics as the first-choice long-term option for eligible patients with Pseudomonas aeruginosa infection, to minimise systemic side effects and resistance.

Mucoactive Therapy

• NICE: Recommends considering a trial of nebulised mucolytic therapy (e.g., DNase [dornase alfa], hypertonic saline) for patients with an FEV1 >50% predicted and difficulty expectorating sputum, but advises against the use of DNase due to a lack of proven benefit and potential harm.
• BTS: Advises that DNase should not be used routinely in stable non-CF bronchiectasis, reflecting the same evidence base as NICE. It recommends considering nebulised mannitol or hypertonic saline for patients with frequent exacerbations despite optimal ACTs.

Key Difference & Practical Takeaway

Long-term Antibiotic Strategy: NICE provides a clearer threshold (3 exacerbations) for initiation. BTS offers a more cautious, step-up approach, prioritising nebulised antibiotics for Pseudomonas-infected patients to reduce systemic antibiotic exposure. In practice, the choice may depend on local microbiology, patient preference, and resource availability for nebuliser services.

Special Situations

Non-Tuberculous Mycobacteria (NTM)

• NICE: Advises referral to a specialist centre with expertise in NTM management.
• BTS: Provides detailed, specific recommendations on diagnosis (requiring multiple positive cultures), indications for treatment (based on symptoms and radiological progression), and complex multi-drug regimens.

Takeaway: BTS is the more comprehensive resource for managing NTM infection.

Aspergillus Sensitisation and Allergic Bronchopulmonary Aspergillosis (ABPA)

• NICE: Recommends testing for Aspergillus sensitisation as part of the initial workup.
• BTS: Provides detailed diagnostic criteria for ABPA and specific treatment guidance involving oral corticosteroids and antifungal agents.

Bronchiectasis in COPD Overlap

Both guidelines acknowledge this common overlap. Management should focus on treating both conditions according to their respective guidelines, with particular attention to sputum culture to guide antibiotic therapy during exacerbations.

Practical Clinical Flow

A hybrid approach, drawing on both guidelines, might look like this:

1. Suspicion: Chronic cough and sputum.
2. Confirm: Diagnose with HRCT chest.
3. Assess & Investigate:
   • Perform baseline spirometry.
   • Initiate BTS-tiered first-line tests (FBC, Ig, Aspergillus IgE, autoantibody screen, sputum culture, protein electrophoresis).
   • Calculate BSI/E-FACED score.
4. Treat & Manage:
   • Educate and train on daily ACTs.
   • Treat exacerbations promptly with targeted antibiotics.
   • For patients with ≥3 exacerbations/year despite ACTs, consider long-term antibiotics. Per BTS, favour nebulised antibiotics if Pseudomonas is present.
   • Consider a trial of nebulised hypertonic saline or mannitol for difficult sputum.
5. Refer: Refer to specialist centre for NTM, complex cases, or consideration of surgery.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow in my NHS practice?

Both are relevant. NICE guidelines often carry more weight for commissioning and standardising care across the NHS. The BTS guideline provides deeper, specialist-level detail. Using NICE's structure with BTS's investigative and treatment nuances is a common and effective approach.

2. A patient has 4 exacerbations a year. Should I start oral or nebulised antibiotics?

First, ensure ACTs are optimised. If sputum is culture-positive for Pseudomonas aeruginosa, the BTS guideline strongly suggests trying nebulised antibiotics first (e.g., colistimethate sodium). For other organisms, the decision is less clear-cut; discuss the pros (reduction in exacerbations) and cons (side effects, resistance) with the patient. NICE allows for either option.

3. Is dornase alfa (DNase) ever recommended?

No. Both NICE and BTS advise against the routine use of DNase in stable non-CF bronchiectasis, based on evidence showing lack of efficacy and potential for harm.

4. How should I monitor stable patients?

Both guidelines agree on monitoring sputum volume and purulence, exacerbation frequency, quality of life, and spirometry (annually for stable patients, more frequently if unstable). The BTS places a stronger emphasis on using validated quality of life questionnaires.

5. What is the key difference in philosophy between the two guidelines?

NICE aims for a pragmatic, standardised, and cost-effective approach suitable for a broad audience. BTS offers a comprehensive, specialist-focused guide with detailed management strategies for complex scenarios, reflecting a more cautious approach to interventions like long-term oral antibiotics.

Source Links

• NICE Guideline NG.117 (Dec 2023 update): NICE NG117
• BTS Guideline for Bronchiectasis in Adults (2019, 2023 update): BTS guideline: bronchiectasis