Myasthenia gravis (MG) is the most common disorder of the neuromuscular junction. Myasthenia crisis, defined as respiratory failure requiring mechanical ventilation in MG, is a common Life-threatening complication that occurs in approximately 15% to 20% of patients with MG during their life time. The advent of effective mechanical ventilation, specialized neurointensive care units and the widespread use of immunotherapies have substantially altered the prognosis of myasthenic crisis. Early intubation and mechanical ventilation is perhaps the most important step in the management of myasthenic crisis. The authors favor an orotracheal approach for intubation, and placement of small bore duodenal tubes that may help decrease the risk of aspiration and may be more comfortable than regular nasogastric tubes for the patient. Plasma exchange may be more effective than the intravenous immunoglobulin in the treatment of myasthenic crisis involving respiratory failure. A randomized trial is required to confirm the superior efficacy of plasma exchange compared with intravenous immunoglobulin. In the acute setting, the role of immunosuppression and intravenous/intramuscular pyridostigmine and the newer agents such as tacrolimus remains limited and at times controversial. The therapy should be tailored at an individual basis using best clinical judgment.