The ability of hyperpolarised gas MRI to translate into real-world clinical practice is unknown. 129Xe ventilation images were acquired as part of routine care in patients referred from a difficult asthma service, and evaluated by a multi-disciplinary team. Evidence of airways obstruction on MRI can support the use of further treatment, for example in those with normal spirometry and high symptom burden. Well preserved ventilation on MRI alongside poor spirometry and/or symptom control may suggest coexisting breathing control issues or laryngeal disorders. 129Xe MRI can provide additional unique and valuable information in the evaluation of clinical presentations of asthma.