A 39-year-old woman was referred for refractory asthma. The patient presented with daily symptoms of cough, chest tightness, wheezing, and dyspnea. Breathing symptoms typically awakened her three times per night. Although she continued to work full time, her daytime activities were restricted. Despite a number of controller medications including salmeterol, fluticasone, montelukast, zileuton, omalizumab, cetirizine, methotrexate, and 60 mg of prednisone, 8 to 24 puffs of an albuterol rescue inhaler were needed per day for acute relief. She gave a history of being diligent with her medication regimen and known allergen avoidance and was a life-long nonsmoker. Since asthma was diagnosed 15 years previously, she experienced a progressive worsening of symptoms with frequent exacerbations, one of which required endotracheal intubation in 1998.