Pulmonary nocardiosis is a rare opportunistic infection with nonspecific symptoms, which often delays diagnosis and treatment. The article describes three confirmed cases: the first in an elderly patient with bronchiectasis diagnosed by sputum tNGS and successfully treated with trimethoprim-sulfamethoxazole; the second in a patient with bronchiectasis and COPD diagnosed by tNGS of BAL fluid who switched to linezolid due to intolerance; the third in a patient with structural lung disease where a long-standing infection was eventually controlled by combination antimicrobial therapy. A literature analysis of 119 patients showed a median age of 57 years, male predominance (55.5%), comorbidities such as chronic lung disease (39.5%) and immunosuppression (39.5%). Chest CT was dominated by consolidations (47.9%) and nodules (41.2%), diagnosis by sputum (48.7%) or BAL fluid (42.9%), and 83.2% of patients received trimethoprim-sulfamethoxazole. Patients with tNGS and/or bronchoscopy had a trend towards lower mortality. Accurate diagnosis by bronchoscopy and tNGS in combination with individualized sensitivity-controlled therapy improves results, with the need to monitor adverse effects during long-term treatment.