## 4 Discussion  
This paper is the result of the consensus of an expert panel on the main issues related to the management of adult asthma patients in the ED during the COVID-19 pandemic. Patients with acute or worsening or exacerbating asthma are often guests in our EDs [5]. However, clinical studies on this setting (especially of high-quality) are lacking, and most guidelines and review articles did not assess this specific topic or treat it marginally [3, 57, 88, 89, 90, 91, 92, 93, 94, 95]. To best care for such type of patient, especially in the current era, it is essential to identify the right COVID-19 path and best management in the ED and, after hospital discharge, the most innovative and functional follow-up options. Regarding the first key point, no literature data are available on which is the right COVID-19 path for adult asthma patients. In EDs around the world, it was necessary to revise clinical paths and create separate areas to prevent the spread of in-hospital infection from SARS-CoV-2. In light of the literature evidence and, perhaps more importantly, of the common sense of those who know the dynamics of the ED in depth, the expert panel suggested a plausible COVID-19 path to be used for asthma patients. Although preCOVID-19 guidelines do not recommend first-line chest imaging in all asthmatics attending the ED, our suggestion to perform it arose from the rationale of assessing for possible concomitant SARS-CoV-2 pneumonia [20,21]. There is also a lack of specific data in the literature on the management of asthma attacks in adult patients within the ED. The proposal of several scientific societies or review articles to avoid nebulizers for the administration of bronchodilators and topic corticosteroids arose in the context of appropriate infection control precautions. Our expert panel agreed with this preference but, in the absence of solid evidence, suggested utilizing the available devices to minimize the delay in drug administration. This applies not only to severe attacks, where there is generally no doubt about the indication for nebulization, but also to non-severe ones, because in acute asthma, prompt therapy prevents worsening of the clinical picture. Moreover, in the absence of specific literature data, the pharmacological treatment of acute asthma and the indication of oxygen support and/or respiratory assistance remain unchanged, also in case of concomitant COVID-19. There is no strong evidence against the administration of systemic corticosteroids, even in patients with SARS-CoV-2 infection, if indicated for asthmatic clinical picture. Thus, our suggestion was in line with the literature data and is similar to most guidelines and review articles that specifically address the issue of administration of these drugs in patients with asthma exacerbation. Even in the case of the third key point, namely the suggestion to implement an e-health system for the management and follow-up of adult patients with asthma discharged from the ED, the suggestion of the panel agreed with the available literature and guideline recommendations. In our view, the main strength of this paper was to provide the first focused, most comprehensive, up-to-date and educational guideline possible for the management of asthma patients in the ED at the time of COVID-19. To do so, we combined an exhaustive review of the available literature with a consensus among experts from the three main disciplines involved in the management of asthma (emergency medicine physicians, pulmonologists and allergists), balancing the presence of specialists from university and community hospitals. This process allowed discussion of best practices in the absence of high-quality evidence. In fact, lacking robust literature data, it was not possible to provide a systematic literature review consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards [96]. However, the absence of targeted and high-quality findings on which to base recommendations remains a limit.