Can bronchial asthma with an highly prevalent airway (and systemic) vagal tone be considered an independent asthma phenotype? Possible role of anticholinergics

Recently, we studied occurrence and role of non-respiratory symptoms (n-RSs) before a worsening of asthma symptoms. Some n-RSs such as anxiety, reflux, heartburn, abdominal pain, which appeared within 3 h before the onset of an asthma attack, are the likely result of an imbalance between sympathetic/parasympathetic systems with an increase in cholinergic tone. Therefore, it is likely that some of these n-RSs induced by the increased cholinergic tone might be present related with specific parasympathetic-associated respiratory symptoms such as those elicited by airway narrowing. It is likely that, at least in some categories of asthmatics, an increased cholinergic tone, rather than other well-known factors, might play a prevalent role in triggering bronchospasm. If this is the case, it is possible to speculate that the use of anticholinergic agents (mainly those with long-acting activity) in patients suffering from asthma should be more beneficial in individuals characterized by a higher degree of cholinergic tone that, consequently might be the ideal target for the use of long-acting anticholinergics and, possibly, represent a novel asthma phenotype. The presence of parasympathetic-associated n-RSs might help the physician to identify this type of patients, although this might be followed by a more detailed assessment.