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The traditional view of asthma has changed considerably during the last decades. A paradigm shift in our understanding of asthma has turned our focus from the importance of muscle spasm to inflammation. Today asthma is believed to be a central airway inflammatory disorder, and the importance of activated eosinophils found in central airway biopsies and in induced sputum is believed to be a hallmark of this inflammatory process. Anti-inflammatory treatment in asthma has for long been seen as treatment with cortisone. Moreover, the view of asthma as mainly a central airway disorder, make it logic to treat this what is believed to be a central airway disorder, locally by the inhaled route. During the recent year we have gained a lot of new knowledge challenging the current view of asthma. While previous asthma treatment guidelines mainly have focused on asthma as a organ disorder, more modern guidelines such as ARIA (Allergic Rhinitis and its Impact on Asthma) have revealed the necessity of treating not only the lower but also the upper airways. It is also clear that corticosteroid therapy do not suppress all parts of the asthmatic inflammation and other, more or less “steroid refractory mechanisms” ask for complementary strategies in order to achieve a better control of the asthmatic inflammation. Finally, not only the upper airways seem to be commonly involved in asthma patients. The peripheral “small airways” and the lung parenchyma, as well as organs outside the thorax, contribute to the inflammatory burden of the disease. Thus in order to be able to advance further in our management strategies we need to change our view of asthma from an organ centred to a more systemic approach. It is really time for a paradigm shift!

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