Despite recent advances in our ability to manage asthma, there continues to be a small but important incidence of patients who present with severe asthma exacerbations that require ventilatory support. Mechanical ventilation in these patients is difficult and can be associated with substantial morbidity. Unfortunately, there is little in the way of randomized controlled trials to guide our therapeutic decisions in these patients. The goal is to provide adequate gas exchange while minimizing hyperinflation and ventilator-induced lung injury and administering aggressive therapy to reduce airway inflammation and bronchoconstriction. Although there is controversy on exactly what is the optimal method for mechanical ventilation in asthma, most experts agree that a general approach based on controlled hypoventilation is ideal.