Features of the courses in 12 children who died of an acute attack of asthma were compared with those in 12 children of comparable age and sex who had a life-threatening attack of asthma but survived. Information obtained by structured interviews with the families and physicians and from the medical records was used to characterize (1) the patient, family, severity, and treatment of asthma primarily in the 6 months before the attack and (2) medical circumstances and patient characteristics present on the day of and/or during the acute episode. Patients in the study (mean age, 14.1 years) and controls (mean age, 13.8 years) were in early to late adolescence, had similar long-term medication use histories and an overall rating of the severity of asthma. For the analysis of the information concerning the 6 months before the attacks, the study patients had a greater frequency of respiratory failure requiring intubation, a decrease in steroid use in the month before the attack, history of family disturbance, abnormal reaction to separation or loss, and expressed hopelessness and despair. For the period more immediately surrounding the acute attack, study patients more often had attacks starting during sleep, but less frequently experienced vomiting during the course of the attacks. Treatment of the attack by the parents was poor (primarily because of delays) in 7 of the 12 children who died, but was also a factor in 6 of the 12 controls. Our data suggest that certain characteristics of asthmatic children may place them at greater risk for death due to their asthma. In addition, we postulate that there may be inherent differences in the mechanisms of the acute attacks between the children who died and those who survived.