Successful Management of Ventilation-refractory Severe Asthma with Extreme Hypercapnia using Venovenous Extracorporeal Membrane Oxygenation

Abstract Acute severe asthma may rarely progress to extreme hypercapnic respiratory failure, challenging conventional mechanical ventilation. We report the case of a 16-year-old adolescent with severe asthma who developed life-threatening hypercapnia (PaCO 2 : 227 mmHg, pH: 6.70) refractory to maximal medical therapy and lung-protective mechanical ventilation. Ventilatory pressures rapidly became unsafe due to severe dynamic hyperinflation. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated as a rescue strategy for controlled decarboxylation. Rapid physiological stabilization was achieved, with normalization of PaCO 2 within 24 h and no neurological complications. ECMO was successfully weaned after 7 days, followed by uneventful extubation. This case highlights the role of VV-ECMO as a targeted decarboxylation strategy in ventilation-refractory acute severe asthma.