Asthma is a common chronic respiratory disease where exacerbations can be associated with significant morbidity, mortality, and economic burden. Severe asthma exacerbations (SAEs) represent life-threatening episodes of symptom burden that require intensive care treatment. While outpatient asthma management is well-established by major organizational guidelines, there are limited evidence-based recommendations for treatment of SAEs requiring intensive care. This narrative review synthesizes current literature regarding conventional inpatient asthma therapies, ventilation strategies, and emerging rescue modalities for management of SAEs, including inhaled anesthetics and veno-venous extracorporeal membrane oxygenation and discusses future areas of interest for research. Until more robust clinical data is available, intensivists should weigh the potential risks and benefits of more advanced rescue therapies and consider a multidisciplinary approach to determining those most likely to benefit from these interventions.
MoormanJERuddRAJohnsonCA, et al.National surveillance for asthma–united states, 1980-2004. MMWR Surveill Summ2007; 56: 1–54.
2.
PendergraftTBStanfordRHBeasleyR, et al.Rates and characteristics of intensive care unit admissions and intubations among asthma-related hospitalizations. Ann Allergy Asthma Immunol2004; 93: 29–35. https://doi.org/10.1016/S1081-1206(10)61444-5
Menzies-GowACorrenJBourdinA, et al.Tezepelumab in adults and adolescents with severe, uncontrolled asthma. N Engl J Med2021; 384: 1800–1809. https://doi.org/10.1056/NEJMoa2034975
5.
CastroMCorrenJPavordID, et al.Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma. N Engl J Med2018; 378: 2486–2496. https://doi.org/10.1056/NEJMoa1804092
6.
NairPWenzelSRabeKF, et al.Oral glucocorticoid-sparing effect of benralizumab in severe asthma. N Engl J Med2017; 376: 2448–2458. https://doi.org/10.1056/NEJMoa1703501
HolguinFCardetJCChungKF, et al. Management of severe asthma: a European respiratory society/american thoracic society guideline. Eur Respir J. 2020; 55(1): 1900588. https://doi.org/10.1183/13993003.00588-2019
9.
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated 15 November 2025. Available from:www.ginasthma.org
10.
GayenSDachertSLashariBH, et al.Critical care management of severe asthma exacerbations. J Clin Med2024; 13: 859. https://doi.org/10.3390/jcm13030859
EmermanCLCydulkaRK. A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma. Chest1995; 107: 1559–1563. https://doi.org/10.1378/chest.107.6.1559
15.
ManserRReidDAbramsonM. Corticosteroids for acute severe asthma in hospitalised patients. Cochrane Database Syst Rev2000; 2001: CD001740. https://doi.org/10.1002/14651858.CD001740
SuehsCMMenzies-GowAPriceD, et al.Expert consensus on the tapering of oral corticosteroids for the treatment of asthma. A Delphi study. Am J Respir Crit Care Med2021; 203: 871–881. https://doi.org/10.1164/rccm.202007-2721OC
18.
CraigSSDalzielSRPowellCV, et al.Interventions for escalation of therapy for acute exacerbations of asthma in children: an overview of cochrane reviews. Cochrane Database Syst Rev2020; 8: CD012977. https://doi.org/10.1002/14651858.CD012977.pub2
19.
JohnsonAJSpiroSGPidgeonJ, et al.Intravenous infusion of salbutamol in severe acute asthma. Br Med J1978; 1: 1013–1015. https://doi.org/10.1136/bmj.1.6119.1013
20.
CamargoCAJrSpoonerCHRoweBH. Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev2003; 2003: CD001115. https://doi.org/10.1002/14651858.CD001115
21.
CydulkaRKEmermanCLMuniA. Levalbuterol versus levalbuterol plus ipratropium in the treatment of severe acute asthma. J Asthma2010; 47: 1094–1100. https://doi.org/10.3109/02770903.2010.517337
22.
SinghAKGaurSKumarR. A randomized controlled trial of intravenous magnesium sulphate as an adjunct to standard therapy in acute severe asthma. Iran J Allergy Asthma Immunol2008; 7: 221–229.
GoodacreSCohenJBradburnM, et al.The 3Mg trial: a randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma. Health Technol Assess2014; 18: 1–168. https://doi.org/10.3310/hta18220
ShimC. Adrenergic agonists and bronchodilator aerosol therapy in asthma. Clin Chest Med1984; 5: 659–668.
28.
NaspitzCKSoleDWandalsenN. Treatment of acute attacks of bronchial asthma. A comparative study of epinephrine (subcutaneous) and fenoterol (inhalation). Ann Allergy1987; 59: 21–24.
29.
HeshmatiFZeinaliMBNorooziniaH, et al.Use of ketamine in severe status asthmaticus in intensive care unit. Iran J Allergy Asthma Immunol2003; 2: 175–180.
30.
HowtonJCRoseJDuffyS, et al.Randomized, double-blind, placebo-controlled trial of intravenous ketamine in acute asthma. Ann Emerg Med1996; 27: 170–175. https://doi.org/10.1016/s0196-0644(96)70319-0
La ViaLSanfilippoFCuttoneG, et al.Use of ketamine in patients with refractory severe asthma exacerbations: systematic review of prospective studies. Eur J Clin Pharmacol2022; 78: 1613–1622. https://doi.org/10.1007/s00228-022-03374-3
33.
BondKRHorsleyCAWilliamsAB. Non-invasive ventilation use in status asthmaticus: 16 years of experience in a tertiary intensive care. Emerg Med Australas2018; 30: 187–192. https://doi.org/10.1111/1742-6723.12876
34.
WoodLDEngelLAGriffinP, et al.Effect of gas physical properties and flow on lower pulmonary resistance. J Appl Physiol1976; 41: 234–244. https://doi.org/10.1152/jappl.1976.41.2.234
35.
ColebournCLBarberVYoungJD. Use of helium-oxygen mixture in adult patients presenting with exacerbations of asthma and chronic obstructive pulmonary disease: a systematic review. Anaesthesia2007; 62: 34–42. https://doi.org/10.1111/j.1365-2044.2006.04897.x
JollietPOuanes-BesbesLAbrougF, et al.A multicenter randomized trial assessing the efficacy of helium/oxygen in severe exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med2017; 195: 871–880. https://doi.org/10.1164/rccm.201601-0083OC
38.
BourdinACharriotJBoissinC, et al.Will the asthma revolution fostered by biologics also benefit adult ICU patients?Allergy2021; 76: 2395–2406. https://doi.org/10.1111/all.14688
39.
KimBGParkDWParkTS, et al.A case of biologic use in acute asthma exacerbation refractory to conventional management. J Allergy Clin Immunol Pract2023; 11: 2922–2925. https://doi.org/10.1016/j.jaip.2023.06.064
40.
Perez de LlanoLBlanco CidNOrtiz PiquerM, et al.Compassionate use of a single dose of benralizumab in a near-fatal asthma exacerbation. J Investig Allergol Clin Immunol2021; 31: 268–270. https://doi.org/10.18176/jiaci.0609
41.
RamakrishnanSCampJRVijayakumarB, et al.The use of benralizumab in the treatment of near-fatal asthma: a new approach. Am J Respir Crit Care Med2020; 201: 1441–1443. https://doi.org/10.1164/rccm.202001-0093LE
42.
Grasmuk-SieglEXheliliEDobererD, et al.Tezepelumab in a case of severe asthma exacerbation and influenza-pneumonia on VV-ECMO. Respir Med Case Rep2024; 50: 102057. https://doi.org/10.1016/j.rmcr.2024.102057
43.
KroesJAZielhuisSWBethlehemC, et al.Administration of benralizumab in a patient with severe asthma admitted to the intensive care unit with COVID-19 pneumonia: case report. Eur J Hosp Pharm2022; 29: 235–236. https://doi.org/10.1136/ejhpharm-2020-002660
44.
AdiOApooFNFongCP, et al.Inhaled volatile anesthetic gas for severe bronchospasm in the emergency department. Am J Emerg Med2023; 68: 213.e5–213.e9. https://doi.org/10.1016/j.ajem.2023.04.032
LewAMorrisonJMAmankwahEK, et al.Volatile anesthetic agents for life‐threatening pediatric asthma: a multicenter retrospective cohort study and narrative review. Pediatric Anesthesia2021; 31: 1340–1349. https://doi.org/10.1111/pan.14295
48.
RookeGAChoiJ-HBishopMJ. The effect of isoflurane, halothane, sevoflurane, and thiopental/nitrous oxide on respiratory system resistance after tracheal intubation. Anesthesiology1997; 86: 1294–1299. https://doi.org/10.1097/00000542-199706000-00010
49.
GillBBartockJLDamuthE, et al.Case report: isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med2022; 9: 1051468. https://doi.org/10.3389/fmed.2022.1051468
50.
MondoñedoJRMcNeilJSAminSD, et al.Volatile anesthetics and the treatment of severe bronchospasm: a concept of targeted delivery. Drug Discov Today Dis Model2015; 15: 43–50. https://doi.org/10.1016/j.ddmod.2014.02.004
51.
HoGWKThaarunTEeNJ, et al.A systematic review on the use of sevoflurane in the management of status asthmaticus in adults. Crit Care2024; 28: 334. https://doi.org/10.1186/s13054-024-05122-8
52.
ShankarVChurchwellKBDeshpandeJK. Isoflurane therapy for severe refractory status asthmaticus in children. Intensive Care Med2006; 32: 927–933. https://doi.org/10.1007/s00134-006-0163-0
53.
SchutteDZwitserlootAMHoumesR, et al.Sevoflurane therapy for life-threatening asthma in children. Br J Anaesth2013; 111: 967–970. https://doi.org/10.1093/bja/aet257
54.
CarriéSAndersonTA. Volatile anesthetics for status asthmaticus in pediatric patients: a comprehensive review and case series. Paediatr Anaesth. 2015; 25(5): 460–467. https://doi.org/10.1111/pan.12577
55.
LaGrewJEOlsenKRFrantzA. Volatile anaesthetic for treatment of respiratory failure from status asthmaticus requiring extracorporeal membrane oxygenation. BMJ Case Rep2020; 13: e231507. https://doi.org/10.1136/bcr-2019-231507
KimHYLeeJEKimHY, et al.Volatile sedation in the intensive care unit: a systematic review and meta-analysis. Medicine2017; 96: e8976. https://doi.org/10.1097/MD.0000000000008976
58.
KomeswaranKToddTDWrightT, et al.Outcomes in patients who received ECMO and/or volatile anesthetics as rescue therapies for status asthmaticus. J Extra Corpor Technol2024; 56: 114–119. https://doi.org/10.1051/ject/2024008
59.
HebbarKBPetrillo-AlbaranoTCoto-PuckettW, et al.Experience with use of extracorporeal life support for severe refractory status asthmaticus in children. Crit Care2009; 13: R29. https://doi.org/10.1186/cc7735
MikkelsenMEWooYJSagerJS, et al.Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J2009; 55: 47–52. https://doi.org/10.1097/MAT.0b013e3181901ea5
62.
YeoHJKimDJeonD, et al.Extracorporeal membrane oxygenation for life-threatening asthma refractory to mechanical ventilation: analysis of the extracorporeal life support organization registry. Crit Care2017; 21: 297. https://doi.org/10.1186/s13054-017-1886-8
63.
WarrenAChiuYDVillarSS, et al.Outcomes of the NHS England national extracorporeal membrane oxygenation service for adults with respiratory failure: a multicentre observational cohort study. Br J Anaesth2020; 125: 259–266. https://doi.org/10.1016/j.bja.2020.05.065
64.
VutipongsatornKFujitakeESinghS. Extracorporeal membrane oxygenation in life-threatening asthma unresponsive to mechanical ventilation: a comparison of patient demographics and outcomes between a large london-based intensive care unit and an international registry. Clin Med2019; 19: s19. https://doi.org/10.7861/clinmedicine.19-3s-s19
65.
Di LascioGPriftiEMessaiE, et al. Extracorporeal membrane oxygenation support for life-threatening acute severe status asthmaticus. Perfusion. 2017; 32: 157–163.
66.
BrombergerBJAgerstrandCAbramsD, et al.Extracorporeal carbon dioxide removal in the treatment of status asthmaticus. Crit Care Med2020; 48: e1226–e1231. https://doi.org/10.1097/CCM.0000000000004645
67.
ZakrajsekJKMinSJHoPM, et al.Extracorporeal membrane oxygenation for refractory asthma exacerbations with respiratory failure. Chest2023; 163: 38–51. https://doi.org/10.1016/j.chest.2022.09.029
68.
WangLYangFZhangS, et al.Percutaneous versus surgical cannulation for femoro-femoral VA-ECMO in patients with cardiogenic shock: results from the extracorporeal life support organization registry. J Heart Lung Transplant2022; 41(4): 470–481. https://doi.org/10.1016/j.healun.2022.01.009
69.
DoufléGO'NeilERAbreuS, et al.Ultrasound in extracorporeal membrane oxygenation: an ELSO state-of-the-art review. ASAIO J2026; 72(2): 85–98. https://doi.org/10.1097/MAT.0000000000002656
