## 3 Results of the Survey
### Management of Adult Patients with Asthma in the ED at the Time of COVID-19 Pandemic  
#### 3.2.1 Assessing Patients' Symptoms  
In the ED, the first step in asthma management is to determine the severity of the patient's symptoms at the time of admission [2]. Asthma exacerbation can be classified as mild, moderate and severe. The initial assessment should always include the ABCDE approach: if the patient shows drowsiness, confusion or silent chest, they are a candidate for intubation and admission to the intensive care unit (ICU). Patients unable to speak a few words, who strive to complete simple sentences, with visibly severe dyspnea, fatigued at rest and who need priority in the assessment and treatment, are cases of severe asthma. Moreover, respiratory rate >25 breaths/min, heart rate >110 beats/min and peripheral arterial oxygen saturation (SpO\({}_{2}\)) <90% require immediate medical intervention [23].  
The symptoms and signs described above, associated with wheezing, bronchospasm and elevated respiratory rate, make the diagnostic hypothesis of asthma likely, even if other alternative diagnoses (e.g., bacterial pneumonia, bronchiectasis, pulmonary embolism, chronic obstructive pulmonary disease) must be ruled out. Yet, in the context of the SARS-CoV-2 pandemic, the diagnosis of asthma is a challenge for emergency physicians because of the overlap with COVID-19 respiratory symptoms [22; 24; 25].  
Patients with severe COVID-19 disease often present with dyspnea, elevated respiratory rate, elevated compensatory heart rate, chest discomfort and dry cough, mimicking a severe asthma attack. A previous history of asthma, the presence of audible wheezing, rapid improvement of symptoms after taking beta-agonists and corticosteroids medications  
Figure 1: Panel proposal of a rational “COVID-19 path” during a SARS-CoV-2 pandemic for the management of asthma patients in the emergency department (ED) from admission to discharge. Abbreviations and symbols: BP: blood pressure; HR: heart rate; RR: respiratory rate; BT: body temperature; SpO\({}_{2}\): peripheral arterial oxygen saturation; GCS: Glasgow Coma Scale; +: positive; –: negative; swab: molecular nasopharyngeal swab for SARS-CoV-2.  
and the absence of fever suggest asthma exacerbation. On the contrary, patients with COVID-19 disease often access the ED with fever and dyspnea, have a history of close contact with positive cases, absence of wheezing and may present other symptoms such as mylalgia, fatigue, headache, which are rare in asthma exacerbations. Moreover, they do not improve with inhaled medications.  
On the other hand, since asthma patients have an increased susceptibility to viral infections [26], there is the potential to find a mixed picture of asthma exacerbation and COVID-19 infection in the same patient [24]. Current guidelines recommend measurement of peak expiratory flow (PEF), when available directly in the ED, to objectively asthma severity, rather than signs and symptoms alone. In fact, PEF \(<\)50% indicates severe asthma, while PEF 50-75% indicates moderate asthma [3; 27; 28; 29; 30; 31].  
Because of the current pandemic and the associated risk of virus spread, experts suggest measuring PEF in an open space. PEF could be also useful in differential diagnosis between asthma and COVID-19, given the absence of an obstructive component in the latter.  
However, in our opinion, PEF is not an easy test to perform in the ED because of overcrowding, the small number of open spaces and risk of transmission of COVID-19 by stimulating cough. In addition, a patient with severe asthma exacerbation and severe respiratory distress dyspnea, who is unable to speak, may not be able to undergo PEF.