Although asthma is a condition that is managed in the outpatient setting in most patients, the poorly controlled and severe cases pose a major challenge to the health-care team. Recognition of the more common insidious and the less common rapid onset “acute asphyxic” asthma are important. The intensivist needs to be familiar with the factors that denote severity of the exacerbation. The management of respiratory failure in asthma, including pharmacologic and mechanical ventilation, are discussed in this article. Two important complications of the positive-pressure ventilation, the dynamic hyperinflation and barotrauma, may be life-threatening. Interventions with helium-oxygen mixtures, anesthesia, and paralysis may be considered in certain situations.