Airways of patients with bronchial hyperreactivity (BHR) are characterised by exaggerated bronchoconstriction in response to a variety of stimuli; bronchospasm may be elicited during induction and maintenance of anaesthesia. The prevalence of BHR in normal populations is approximately 10%. BHR is an important feature of clinical asthma, chronic obstructive pulmonary disease (COPD), allergic rhinitis, atopy, upper respiratory tract infections and smoking. This review will outline some important aspects of the pathophysiological basis of BHR, i.e., neural and inflammatory mechanisms. Furthermore, it should assist in identifying patients at risk and update perioperative anaesthetic considerations. Prophylaxis of airway reflex activation and an appropriate anaesthetic plan should prevent airway constriction. Since tracheal intubation is the major risk factor to induce bronchospasm intubation should be avoided whenever possible and regional anaesthesia preferred. If tracheal intubation is unavoidable, propofol and ketamine can be recommended as induction agents. Prophylaxis of intraoperative bronchospasm and initial therapy, such as deepening of anaesthesia, inhalational administration of sympathomimetics and anticholinergics, and i.v. use of local anaesthetics and corticosteroids are outlined. Despite its popularity theophylline offers little benefit during anaesthesia. Adequate preoperative evaluation and preparation of the patient with BHR will contribute to optimising anaesthetic management of patients with BHR.