ERS 2025 vs. CHEST 2026: Why the ERS Bronchiectasis Guidelines Remain the Better Choice for Clinicians
Nicole “Nic” Narain, DNP, MSN-PH, APRN, FNP-C, ENP-C
Two major society guidelines for adult bronchiectasis were published within one year of each other: the European Respiratory Society (ERS) guideline in 2025 and the American College of Chest Physicians (CHEST) guideline in 2026 (Chalmers et al., 2025; Thomson et al., 2026). Both utilized the GRADE methodology and were developed to introduce more structure to a historically under-researched disease. For providers seeking a single, comprehensive reference, the ERS guideline remains the stronger choice.
Scope of the guidelines
The ERS guideline addresses the full scope of bronchiectasis care. It includes a narrative question on identifying underlying causes, calculating the Bronchiectasis Severity Index, and screening for comorbidities, none of which are graded recommendations in the CHEST guideline (Chalmers et al., 2025; Thomson et al., 2026). ERS also issues a dedicated recommendation on pulmonary rehabilitation, an area CHEST does not address as a distinct question. For a provider building a complete care pathway, rather than answering isolated treatment questions, ERS covers more ground.
Strength of evidence
The ERS guideline contains several strong recommendations, including: airway clearance techniques, long-term macrolides, long-term inhaled antibiotics for patients with chronic Pseudomonas infection, and pulmonary rehabilitation (Chalmers et al., 2025). These reflect an improved evidence base compared with the 2017 ERS guideline. CHEST issued thirteen recommendations, all of which are conditional, with the certainty of evidence rated as low or very low for all but two: macrolides and brensocatib, which were rated as moderate (Thomson et al., 2026). A guideline built primarily on conditional, low certainty recommendations offers less support for a provider counseling a patient or defending a treatment decision.
Risk stratification: a key point of divergence
One of the more substantive differences between the two guidelines is their approach to risk assessment. ERS places risk stratification at the center of its framework. Patients are evaluated for prior exacerbation history, baseline symptom severity, underlying cause, and additional risk factors, using tools such as the Bronchiectasis Severity Index to guide ongoing management (Chalmers et al., 2025). CHEST does not offer a comparable overarching risk stratification approach. Its recommendations are organized around individual PICO questions and specific interventions, without an integrated framework for classifying patient risk or tailoring the overall care pathway (Thomson et al., 2026). This distinction shapes how each guideline functions in practice, with ERS supporting a structured, ongoing assessment of patient trajectory, and CHEST better suited to answering discrete clinical questions as they arise.
Divergence in specific therapies
CHEST addresses brensocatib, a DPP-1 inhibitor, and issues a conditional recommendation in its favor based on data from the 2025 phase 3 trial (Thomson et al., 2026). ERS discusses brensocatib as an emerging therapy pending regulatory approval, with a formal recommendation planned for its 2026 update (Chalmers et al., 2025). CHEST also addresses tranexamic acid for hemoptysis and surgical resection as standalone questions; ERS folds these into its broader discussion of the deteriorating patient rather than issuing graded recommendations. ERS offers a more definitive recommendation on the eradication of a first Pseudomonas isolate, in favor, while CHEST concluded the evidence was insufficient to recommend for or against (Chalmers et al., 2025; Thomson et al., 2026).
The bottom line
Both guidelines used rigorous, transparent methodology, and both will influence practice going forward. ERS offers a broader scope, stronger recommendations grounded in a maturing evidence base, and an integrated risk stratification framework covering the full patient journey, from diagnosis through exacerbation management. CHEST’s document adds value to specific questions, particularly brensocatib and surgical referral, but its reliance on conditional, low-certainty recommendations makes it better suited as a supplement than as a primary reference. For day-to-day clinical decision-making, the ERS 2025 guideline should remain the primary resource. A detailed side-by-side summary of both guidelines is provided in the table below.
References
Chalmers, J. D., Haworth, C. S., Flume, P. A., et al. (2025). European Respiratory Society clinical practice guideline for the management of adult bronchiectasis. European Respiratory Journal, 66(6), Article 2501126. https://doi.org/10.1183/13993003.01126-2025
Thomson, R., Thornton, C., Aksamit, T., et al. (2026). Management of adult bronchiectasis: An American College of Chest Physicians clinical practice guideline. CHEST. Advance online publication. https://doi.org/10.1016/j.chest.2026.06.057
