## 3 Results of the Survey
### Management of Adult Patients with Asthma in the ED at the Time of COVID-19 Pandemic
#### 3.2.4 Hospitalization and Discharge of Asthmatic Patients during COVID-19 Disease  
According to the available literature, clinical assessment of patients with asthma attacks admitted to the ED is crucial to decide whether to discharge, observe or hospitalize them [68; 69; 70; 71; 72]. Different levels of severity of asthma attacks (mild, moderate, severe, life threatening, fatal, brittle, etc.) influence this choice [34; 73; 74]. The coexistence of SARS-CoV-2 infection may lead emergency physicians to decide on hospitalization, concerned about the presence of two acute diseases with potential short-term recurrence or evolution [38; 65; 75; 76; 77; 78]. However, as mentioned above, the association between asthma and SARS-CoV-2 infection should not in itself be an indication of hospitalization. The recovery rate was similar between asthmatics and non-asthmatics [79]. Hospitalization is recommended [3; 30; 31; 54; 55; 80] for patients with:  
1. Respiratory failure, severe respiratory distress, cyanosis, use of accessory muscles and altered mental status with impaired consciousness, after treatment and reassessment;
2. Hypoxia with SpO2 < 92% after treatment and elevated PCO2 > 45 mmHg; near fatal asthma; presence of complications (e.g., pneumothorax, pneumococcalinstinum, atelectasis, arrhythmia);
3. History of previous severe asthma attacks (e.g., >3 ED visits or >2 hospitalizations in the past 12 months or previous intubation or management in ICU for asthma);
4. Poor family support or difficulty in reaching the hospital in case of further deterioration;
5. Significant medical comorbidities; psychological problems with concerns about compliance;
6. Recent steroid use;2. Who need medical reassessment because they do not improve adequately with the initial therapy;
3. Whose discharge is unsafe because of concerns about therapy compliance or follow-up. Discharge [3; 30; 31; 54; 55; 80] is indicated for stable patients admitted to the ED with mild to moderate symptoms, who have a good response to inhaled treatments, resolution of bronchospasm, stable oxygen saturation >94% and whose need for fast-acting bronchodilators is <1 dose every 4 h. These patients should be discharged with steroid and nebulizer prescriptions, planned follow-up and counseling for cessation of risk factors when necessary [81]. The Role of Innovative Respiratory Hubs and Telemedicine in the Follow-Up of Adult Patients with Severe Asthma after Discharge from the ED  
The COVID-19 pandemic keeps challenging national and international healthcare systems, overwhelmed in their emergency care units and often unable to provide adequate management of chronic diseases. Recommendations for social distancing and patients' fear of infection during face-to-face visits led, at least initially, to a dramatic reduction in routine clinical follow-ups and execution of diagnostic tests. This has a significant impact on patients with chronic respiratory diseases, particularly severe asthmatics, with an increased risk of worsening airway symptoms, impaired quality of life, acute exacerbations and, as a result, admission to ICU. Therefore, the usual clinical setting of an outpatient asthma clinic needs complete rethinking and restructuring according to a new concept of medical assistance that can ensure patient safety against SARS-CoV-2 infection while delivering high-quality care. From a practical point of view, respiratory healthcare professionals, who are supposed to perform pulmonary function tests and exhaled breath measurements, should adopt protective measures such as gloves, filtering face masks (FFP) 2 or 3, full eye protection, powered air-purifying respirators (PAPRs) and protective clothing [2; 82]. Furthermore, it is recommended to limit direct patient contact and promote compliance with general hygiene measures. In addition, the outpatient clinic should be set as a COVID-free space, with a wide waiting area separated from the consulting room, featuring a good ventilation system.