Severe childhood asthma is a serious, life-threatening disease that presents a challenge for patients, families, and caregivers. Despite evolving medical and pharmacologic therapies, the incidence and severity of asthma are increasing. Vasoactive substances are released in response to environmental and intrinsic triggers and result in bronchospasm, bronchial mucosal edema, and mucus plugging of the airways. Early recognition of symptoms and prompt, aggressive treatment, including oxygen, beta agonists, corticosteroids, and anticholinergic agents, are essential in halting the progression of asthma symptoms. In the most severe cases, intubation, mechanical ventilation, and treatment with anesthetic agents may be needed to avoid significant morbidity and mortality. This article reviews epidemiology, pathophysiology, and acute care of the child experiencing an acute asthma exacerbation.