The importance of symptoms in bronchiectasis.

Bronchiectasis is a chronic respiratory disease characterised by irreversible bronchial dilatation, persistent airway inflammation and recurrent infections. Symptoms, particularly cough, sputum production and dyspnoea, are the most immediate and patient-relevant expression of the disease, linking clinical presentation, airway biology and outcomes. While asthma and COPD management algorithms already integrate symptom burden into therapeutic decision-making, bronchiectasis care has historically relied on exacerbation history to guide preventive interventions. Over the past decade, an expanding body of evidence has demonstrated that daily symptoms mirror current infection and inflammation, profoundly impact quality of life, and predict future exacerbations. Comparative analyses across chronic lung diseases further highlight the central role of symptom monitoring in defining disease activity and risk. The updated European Respiratory Society guidelines translate this evidence into clinical practice, marking a paradigm shift from an exacerbation-driven to a symptom-centred and treatable-traits model. This review synthesises clinical, biological and therapeutic insights linking symptoms to bronchiectasis pathophysiology, disease activity and treatment response. We discuss how airway clearance, mucoactive therapy, antibiotics, pulmonary rehabilitation and targeted anti-inflammatory strategies, including dipeptidyl peptidase-1 inhibition, can address specific symptom profiles. We also mention the role of comorbidities and psychosocial management, establishing symptoms as the cornerstone of a holistic, multidimensional care approach. Recognising symptoms as both biomarkers of activity and therapeutic targets represents a major step toward precision medicine in bronchiectasis, aligning clinical management with patient experience and the biological drivers of disease.