Introduction: Asthma and bronchiectasis are often partners in a complex but uneven relationship with asthma receiving more attentions. The aim of this study is to describe how bronchiectasis are investigated in some Severe Asthma (SA) Centers scattered throughout the Italian territory. Materials and Methods: We enrolled 92 patients with SA and bronchiectasis from 8 Italian SA Centers and recorded diagnostic approaches to investigate SA and bronchiectasis at the time of enrollment (T0), at the 6-month (T1), and at the 12- month (T2) follow-up visits. Results: A statistically significant heterogeneous diagnostic approach emerged across the centers under study In fact, while, as expected, all involved centers made an in-depth investigation of SA, only few of them made a complete investigation of bronchiectasis in order to provide specific treatment. Discussion: This real-life multicenter study confirmed that patients with coexistent SA and bronchiectasis are mainly investigated for pheno-endotyping asthma but rarely for complete assessment of bronchiectasis. We believe that the diagnostic flowchart of SA patients with suspicion or confirmed bronchiectasis needs to be clarified and implemented as the association of these conditions strongly influences final outcomes and management of these patients.

The application of 16S rRNA gene pyrosequencing has expanded our knowledge about the respiratory tract microbiome originally obtained using conventional, culture-based methods. In this study, we employed DNA-based molecular techniques for examining the sputum microbiome in bronchiectasis patients in relation to disease severity. Of 63 study subjects, 42 had mild and 21 had moderate or severe bronchiectasis, which was classified by calculating the FACED score based on FEV₁ (forced expiratory volume in 1 s, %) (F, 0–2 points), age (A, 0–2 points), chronic colonization by Pseudomonas aeruginosa (C, 0-1 point), radiographic extension (E, 0–1 point), and dyspnoea (D, 0–1 point). Bronchiectasis was defined as mild at 0–2 points, moderate at 3–4 points, and severe at 5–7 points. The mean age was 68.0 ± 9.3 years; 33 patients were women. Haemophilus (p=0.005) and Rothia (p=0.043) were significantly more abundant in the mild bronchiectasis group, whereas Pseudomonas (p=0.031) was significantly more abundant in the moderate or severe group. However, the alpha or beta diversity did not significantly differ among sputum microbiota, i.e. the same dominating genera were found in all samples. Further large-scale studies are needed to investigate the sputum microbiome in bronchiectasis.

This manuscript is aimed at encouraging those interested in biofilms and their effects on microbial communities to view the study of chronic airways disease as one of the most challenging and potentially rewarding areas to focus on. To do this it is necessary to review how we have reached 2023 having made so little progress. It is more than two hundred years ago since the term bronchitis was proposed to describe diseases affecting the airways rather than the respiratory zone of the lungs. The main histological features were described in Laennec’s text of 1819. By the mid C20th it was recognised that the two great drivers of chronic respiratory symptoms were inhaled toxins and chronic bacterial infections. The widespread availability of antibiotics in subsequent years had a dramatic impact on mortality from pneumonia, greatly reduced the prevalence of chronic symptoms after acute lower respiratory tract infections, transformed the lives of many with bronchiectasis and appeared to play a major role in the dramatic fall in prevalence of bronchiectasis. Unfortunately, during the following 70 years the importance of dealing with a chronic bacterial bronchitis was largely forgotten. While two artificial diseases ‘COPD’ and ‘bronchiectasis’ have been the subject of numerous guidelines, chronic bacterial bronchitis has been out in the cold. Antibiotics have in theory been reserved for those with established damage in the form of bronchiolitis and impaired lung function as defined by an arbitrary FEV1/FVC ratio and even then there is a disconnect with a minimum of 2 weeks being prescribed for exacerbations of bronchiectasis and the use of long term inhaled and oral macrolides frequently being advocated while a 5 day course is reserved for an exacerbation in a patient with COPD. The loss of focus on the role of antibiotics has a number of causes – a desire to ration antibiotic as part of ‘antibiotic stewardship’, the potential cost of treatment, the failure to ‘cure’ patients with chronic bronchitis and the difficulty in dealing with a disease whose morbidity at any given time can range from a mild cough and production of phlegm in the morning with no obvious impact on daily function to troublesome cough, sputum production and significant ill health. This was compounded by the vagaries of culture based diagnosis and the observation that more than one potential pathogen was often present. As a result chronic bacterial bronchitis was relegated to the ‘too hard to deal with’ box and many of the lessons of the past were forgotten. Revisiting the field from the perspective of current understanding of bacterial behaviour in biofilms and how these alter the resident microbiota of the airways should ensure that a chronic bacterial bronchitis returns to centre stage in order to minimise respiratory morbidity and mortality. This review charts the history of our understanding and mis-understanding of the role of chronic bacterial bronchitis in airways disease and the pernicious effect of language in helping to ensure that this common and important condition became the elephant in the room. Focusing on the nature of chronic bacterial bronchitis is essential if we are to find ways of identifying it accurately and treat it effectively – new approaches will be extremely slow unless we recognise its importance and the challenges it poses.