Mechanical ventilation causes significant morbidity and mortality in patients with severe asthma. Hypoventilation may reduce this morbidity and mortality, but indicators to guide the degree of hypoventilation are unclear. We used a measure of pulmonary hyperinflation to assess the degree of airflow obstruction and to guide the extent and duration of hypoventilation. Ten patients who required mechanical ventilation for acute severe asthma were studied. All were sedated, paralyzed, and given an initial minute ventilation (VE) of 200 ml/kg/min. End-inspiratory lung volume (VEI) above FRC was measured from the total exhaled gas volume during 40 to 60 s of apnea. VEI was used to regulate VE to a safe level (VEsafe), irrespective of PaCO2, by reducing the rate when VEI was > 20 ml/kg and increasing it when VEI was < 20 ml/kg. Each patient was weaned when VEsafe resulted in PaCO2 < or = 40 mm Hg (the weaning point). FRC was measured computer analysis of anterior and lateral chest radiographs taken at the end of apnea. Using the weaning point criterion, 2 patients (PaCO2 < 40 mm Hg) were weaned shortly after arrival. The remaining eight (initial PaCO2, 63 +/- 17 mm Hg) continued hypoventilation until the weaning point was reached (30 +/- 29 h). The weaning point was reached by the VE required for PaCO2 40 mm Hg decreasing concurrent with the VEsafe increasing. All but 1 patient were successfully weaned within 24 h of the weaning point.(ABSTRACT TRUNCATED AT 250 WORDS)