Preoperative Pulmonary Clearance Letter (Pediatric)

Date of Evaluation: [date of evaluation]

Patient: [full name; DOB; MRN; weight in kg]

RE: [patient name], DOB [DOB] — Pulmonary risk assessment for [procedure name] on [planned procedure date / Unknown/TBD]

To: [surgeon/proceduralist name and specialty; anesthesia contact if known; PCP]

From: [pulmonology clinician name, credentials, clinic, contact phone/pager]

Reason for Consult

[Clinical question and indication in 1–2 sentences: why pulmonary assessment was requested, whether procedure is elective or urgent, whether it involves airway instrumentation] This letter provides pulmonary risk stratification and recommendations; final decisions regarding anesthetic plan and day-of-surgery readiness remain with the anesthesia team.

Executive Summary

[One-sentence overview of baseline diagnoses, current stability, and overall pulmonary risk level]

• Baseline respiratory diagnoses and severity: [diagnoses with severity descriptors]
• Current stability status: [baseline symptoms; recent exacerbations; current respiratory supports if any]
• Pulmonary risk level: [Low / Moderate / High] — [one-line rationale]
• Proceed-if: [patient-specific criteria for proceeding]
• Defer/discuss-if: [patient-specific criteria for postponement]
• Top recommendations:
  • [Actionable recommendation 1]
  • [Actionable recommendation 2]
  • [Actionable recommendation 3]
  • [Additional recommendations as applicable]

Baseline Status & Recent Course

Baseline (when well): [typical respiratory state with diagnosis-specific severity markers as relevant] (Include home respiratory supports/equipment with settings if applicable. If none used, state explicitly. Note pertinent prior testing with dates and key values; if unavailable, state reason.)

Recent 4–6 weeks: [timeline of respiratory infections, exacerbations, treatments with explicit dates; current status relative to baseline] (Include recent COVID-19 history if relevant. If no recent illness, state explicitly.)

Assessment & Recommendations

Risk stratification: [Low / Moderate / High] risk for perioperative respiratory adverse events — [supporting rationale]

• Modifiable risk factors: [factors that apply]
• Non-modifiable risk factors: [factors that apply]

Preoperative Optimization

[Medication optimization plan; airway clearance regimen and timing; smoke exposure counseling if relevant; need for anesthesia pre-op clinic or tertiary referral if complexity warrants; additional testing or records needed]

Day-of-Surgery

[Respiratory medications to continue vs hold, listed explicitly; pre-op bronchodilator if recommended; steroid stress-dose consideration if applicable; infection screening criteria that would prompt delay]

Intraoperative Considerations for Anesthesia

[Airway reactivity risk and management considerations; ventilation strategy; aspiration precautions if relevant; pulmonary hypertension precautions if applicable]

Postoperative Plan

[Recommended monitoring level and duration with rationale; oxygenation/ventilation targets; airway clearance resumption timing; opioid-sparing analgesia if OSA/hypoventilation risk; discharge readiness criteria]

Contingency Plans

• If bronchospasm occurs, then [management steps].
• If hypoxemia develops, then [management steps].
• [Additional if/then contingencies as relevant to this patient's risk profile]

Closing

[Who received these recommendations: family/caregiver, surgical team, anesthesia] Please contact pulmonology urgently at [contact number] if the child's respiratory status changes before the procedure date. If the patient's status changes after the evaluation date, this risk assessment may no longer apply; re-contact for reassessment is recommended.

[Follow-up or additional testing plan if applicable]

Sincerely,

[Clinician name, credentials]
[Clinic/service name]
[Contact phone/pager]
[Date and time of signature]

Attachments: [List if included: spirometry report, sleep study summary, ventilator/CPAP settings, imaging, other]