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For the purposes of this review, the term \u2018acute severe asthma\u2019 is used to encompass what has variably been described as near-fatal asthma, status asthmaticus, and life-threatening asthma in the literature. Early recognition of impending respiratory failure, timely intubation and a stepwise approach to supportive interventions are critically important to minimize the risk of mortality and optimize outcomes. Initial treatment focuses on prompt initiation of medical therapies to stabilize ventilation and prevent progression to respiratory failure. If intubated, ventilatory strategies aimed at reducing dynamic hyperinflation and auto-PEEP with permissive hypercapnia need to be considered. When conventional management fails or when barotrauma risk, acid base derangements or hypoxemia become life-threatening, venovenous extracorporeal membrane oxygenation (VV-ECMO) can be utilized as a bridge to recovery. Given its invasiveness, careful patient selection for VV-ECMO is essential. 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