Cellular types in Asthma 

• Eosinophlic (response to steroids as IgE and Type 2 inflammation is involved)
• Non-Eosinophilic (typically steroid resistant) 
• Neutrophilic
• Paucicellular
• Mixed Granulocytic 

Those who had no eiosinophils did not respond to steroids (ICS) but did respond to bronchodilators. So, presence of bronchodilator is not the marker of response to steroids. 

5 clusters of Asthma. 

Why do we need LAMA (long acting anti-muscarinic)

Asthma patient who had bronchoconstriction, JACI 2013 paper, showed that half responded to LABA, while other half responded to LAMA. Hence, both the treatment options should be there. 

Step 3 or more: Consider looking for Endotype (TH 2 vs Non-TH2 inflammation). 

Step 4 or more: Consider adding LAMA . 

Guideline directed therapy is not successful in about 50 % of the cases.