STUDY OBJECTIVE: Difficult airway management is a significant challenge in clinical anesthesia, critical care, and emergency medicine. Inadequate management can lead to severe complications including organ damage and death. This study assessed the variability in difficult airway management across China and focused on how patient and operator factors influenced outcomes in operating rooms. DESIGN: A multicenter observational cross-sectional study. SETTING: This study was conducted from November 2022 to November 2023 and included 25 secondary and tertiary hospitals across various regions in China. PATIENTS: In the total of 181,399 general anesthesia patients, 384 (0.21 %) were identified as having difficult airways. INTERVENTIONS: Data were gathered from a specialized questionnaire comprising four sections with 27 questions and analyzed using logistic regression in SPSS to identify key factors that influenced effective management of difficult airways. MEASUREMENTS: This study focused on preoperative assessment, anesthesia selection, intubation attempts, and contingency planning for difficult airway management practices among anesthesiologists. MAIN RESULTS: In anticipated difficult airways, rapid sequence induction was used in 51.7 % of the cases, maintaining spontaneous breathing under general anesthesia in 11.1 %, and awake intubation in 36 %. For unanticipated difficult airways, 95.9 % of the anesthesiologists opted for rapid sequence induction. Limited mouth opening was the most common cause of difficult airways and obesity and ankylosing spondylitis were identified as significant factors. The logistic regression analysis identified the type of difficult airway, anesthesiologist experience, and assessment methods as key factors influencing the first attempt intubation success. CONCLUSIONS: The accuracy of difficult airway assessment and first attempt intubation success is influenced by both patient-related factors and the anesthesiologist's expertise. Regional and institutional variability in decision-making and tool selection underscores the critical need for standardized guidelines and comprehensive training to enhance airway management outcomes across diverse clinical settings in China.