Asthma is the most common chronic disease of childhood. Although home action plans and the use of maintenance medications have improved daily management and control of asthma, many children still require emergency department care at least once per year. Emergency clinicians must be able to manage patients with acute asthma exacerbations and determine their safe disposition. This issue reviews the current evidence-based emergency department management recommendations for moderate to severe acute asthma in pediatric patients. Timely use of bronchodilators and systemic corticosteroids, as well as adjunct modalities, are discussed. Current challenges in asthma management related to vaping and COVID-19 are also addressed.