The purpose of this study was to describe methods, risk factors, and outcomes of airway management in all patients (obstetrics excluded) attended by anaesthetists over 27 months. Preoperatively, anaesthetists recorded patient factors and assessed four airway characteristics. Methods of tracheal intubation and ease of direct laryngoscopy following general anaesthesia (easy, awkward, difficult) were noted. Factors predictive of poor outcome and the value of the preoperative airway examination were determined. For 18,205 patients following a direct laryngoscopy, (GA), tracheal intubation was difficult (> 2 laryngoscopies) in 1.8% and awkward (< or = 2 laryngoscopies) in 2.5%. This approach was a failure in 0.3%, and surgery was postponed in 0.05%. However, an alternative approach to direct laryngoscopy, (GA) was the first choice in 353 patients. Risk factors for difficult tracheal intubation included male sex, age 40-59 yr and obesity (P < or = 0.01). For direct laryngoscopy, (GA), airway characteristics predictive of difficult tracheal intubation were decreased mouth opening (relative risk 10.3), shortened thyromental distance (9.7), poor visualization of the hypopharynx (4.5), and limited neck extension (3.2), any two (7.6) and more than two (9.4) (P < 0.01). For 1,856 patients (10.0%) where at least one airway characteristic was abnormal, a direct laryngoscopy, (GA) resulted in 8.3% awkward and 6.0% difficult tracheal intubations. For patients with no abnormal airway characteristics, tracheal intubation was easy in 96.3%. Where tracheal intubation was difficult, 34.3% of patients had one or more abnormal airway characteristics preoperatively. Patients with difficult tracheal intubation had an increased rate of desaturation (< 90%), hypertension (> 200 mm Hg) and dental damage on induction of anaesthesia. It is concluded that difficult tracheal intubations occurred infrequently but were associated with increased morbidity. Patient factors and four physical airway characteristics were useful predictors but limited in identifying all problems.