Bone Disease in Non-Cystic Fibrosis Bronchiectasis: Connections, Mechanisms, and Care Gaps.

Abstract

Non-cystic fibrosis bronchiectasis (NCFB) is a heterogeneous chronic airway disease increasingly recognized worldwide and associated with a substantial burden of extra-pulmonary manifestations. Osteoporosis has emerged as a highly prevalent yet underappreciated comorbidity. Unlike cystic fibrosis, where bone health guidelines exist, no screening or management recommendations are available for NCFB despite overlapping risk factors, including chronic inflammation, malnutrition, hypoxia, medication exposure, and physical inactivity. Reported prevalence of osteoporosis and osteopenia in NCFB varies widely (12-70% and 15-40%, respectively), reflecting disease heterogeneity and differences in study methodology. Mechanisms include persistent systemic inflammation, hypoxemia, nutritional deficiencies, and exposure to inhaled or systemic corticosteroids, all of which disrupt bone remodeling. Emerging contributors, such as microbiome dysbiosis and reduced physical activity, may further drive skeletal fragility. Clinically, osteoporosis in NCFB is linked to greater symptom burden, increased comorbidity, poorer quality of life, higher healthcare costs, and elevated mortality. Despite these consequences, bone health is rarely discussed in bronchiectasis literature, and current comorbidity indices do not include osteoporosis as a prognostic factor. This review synthesizes current evidence on the epidemiology, mechanisms, and clinical impact of osteoporosis in NCFB, highlighting significant knowledge gaps and opportunities for early intervention. There is an urgent need for systematic screening, heightened awareness among pulmonologists and primary care clinicians, and interdisciplinary management approaches. Recognizing and addressing this overlooked comorbidity has the potential to improve outcomes and quality of life for patients with NCFB and to inform future disease-specific guidelines.