Fifty eight admissions for 52 adult asthmatics who required intubation were reviewed for the years of 1988-1995 to examine factors related to specific clinical patterns and profile the course of these patients. Of the 56 admissions where patients were intubated for respiratory failure and/or cyanosis, 5 were associated with significant complications of mechanical ventilation/intubation (pneumothorax, subcutaneous emphysema, aspiration pneumonia, and laryngeal edema) and there were no fatalities. Patients > or = 35 years of age had significantly more profound respiratory acidosis in initial arterial blood gases (pH = 7.14 versus 7.23, p = 0.03). In contrast, patients with a history of drug abuse or psychiatric disorders had lower mean pCO2 (p < = 0.01). The overall mean length of intubation was 17.6 hours, while the overall mean hospital stay was 6.6 days. Longer intubation times were associated with the occurrence of major complications, female gender, and hospital administration of ipratropium. Hospital stay was correlated with length of intubation, later month of admission, and earlier year of admission. Common precipitating factors noted for first admissions were upper respiratory infections (61%), followed by allergy or smoke exposure (13%), compliance related problems (12%), and drug abuse/inhalation (6%). Inhaled anti-inflammatory drugs, oral steroids or either were taken at the time of admission by 35%, 35% and 65% of the patients, respectively. There was an even distribution of patients with respect to medical insurance coverage type, admissions per season or year, ethnicity, marital status, and gender. We conclude that severe asthma resulting in respiratory failure is common despite the frequent use of anti-inflammatory asthma medications. Mechanical ventilatory support can be administered safely in the majority of these patients and should be considered early in acute asthma.