Preoperative Pulmonary Risk Assessment

Date/Time: [Date and time of consult completion]

Requesting Clinician/Service: [Requesting clinician or service name]

Reason for Consult: [Clarified reason for pulmonary risk assessment] (If the initial request was vague such as "pulmonary clearance," document the clarification obtained.)

Patient Location: [Current location/setting]

Planned Procedure: [Procedure name; indication; surgical site category; planned approach; expected duration if available; urgency]

Planned Anesthesia: [general / regional / MAC / unknown]

Surgery Date: [Scheduled date / TBD with explanation]

Information Sources: [Patient interview; family/caregiver; EHR; prior records; clinicians] (List only sources actually used.)

Consult Question

[One to three sentences stating the planned procedure and specific questions to be addressed: risk stratification, optimization recommendations, timing guidance, and/or postoperative monitoring needs]

Executive Pulmonary Summary

• [Baseline pulmonary diagnoses and current stability]
• [Baseline oxygenation and respiratory support]
• [Functional capacity with dyspnea context]
• [Overall PPC risk tier: low / intermediate / high] with [main risk drivers]
• [Top recommended mitigation steps]

(Avoid "cleared for surgery" language. Use framing such as: "From a pulmonary standpoint, no additional testing or optimization is recommended before proceeding" or "Pulmonary risk is elevated; recommend the following optimization measures; final proceed decision remains with Surgery/Anesthesia and shared decision-making with the patient.")

History of Present Illness

[Narrative summary beginning with surgical context, then focused pulmonary history: current symptoms (dyspnea baseline vs new, cough, wheeze, chest tightness), recent respiratory infections (especially within one month), recent exacerbations or hospitalizations, baseline exercise tolerance with specific activities (stairs, walking distance), and pertinent sleep-related breathing symptoms] (Use brief patient quotes only when materially clarifying severity or adherence.)

Pulmonary Risk Factor Inventory

Patient-related Factors

• Age: [Age]
• Baseline oxygenation: [SpO₂ on room air and any oxygen requirement]
• Smoking: [current / former / never], [pack-years], [quit date if former]
• Pulmonary diagnoses: [COPD, asthma, ILD, prior lung resection, bronchiectasis with control status] (Include only applicable diagnoses.)
• Heart failure: [History and current status]
• Functional status: [Dependence level and frailty markers if present]
• BMI: [Value] (Include if relevant to OSA or hypoventilation risk.)
• OSA: [Suspected / confirmed]; PAP therapy [yes / no]; adherence [adequate / inadequate / unknown]
• Pulmonary hypertension: [Status if present]
• Aspiration risk factors: [Dysphagia, reflux, neurologic impairment, gastroparesis]
• Relevant labs: [Hemoglobin, albumin if available]

Procedure-related Factors

• Surgical site: [peripheral / lower abdominal / upper abdominal / intrathoracic]
• Emergency status: [elective / urgent / emergent]
• Expected duration: [Duration if known]
• General anesthesia: [yes / no / uncertain]
• Postoperative pain limiting ventilation: [yes / no / uncertain]

Prior Perioperative Respiratory History

• [History of difficult extubation or prolonged ventilation]
• [Prior postoperative pneumonia or atelectasis]
• [Anesthesia-related bronchospasm or aspiration]

(Omit non-applicable items. Use "Unknown" only for decision-critical missing information such as OSA therapy adherence in known severe OSA.)

Objective

Vitals: [HR, BP, RR, Temp, SpO₂ on room air / on O₂ at specified flow, work of breathing, weight and BMI if relevant]

Pulmonary Exam: [Breath sounds, wheeze/crackles, signs of volume overload, cough effectiveness and secretion burden if notable]

Pertinent Data Reviewed:

• Imaging: [CXR/CT with date and key findings] — [One-line interpretation]
• PFTs: [Spirometry ± DLCO with date and key values] — [One-line interpretation]
• Sleep study: [Results and PAP settings/adherence if applicable]
• Labs: [ABG/VBG, Hgb, bicarbonate, albumin as relevant] — [Concise interpretation]

(Include only data actually reviewed.)

Risk Stratification

PPC outcomes considered: [Atelectasis, pneumonia, bronchospasm, aspiration, respiratory failure, prolonged ventilation, reintubation]

Risk assessment: [Validated PPC risk tool name, documented inputs, and calculated result] OR [Qualitative risk tier: low / intermediate / high] with [enumerated key risk drivers]

(If data are insufficient for a formal score, document what is missing and provide a reasoned qualitative estimate.)

Thoracic Surgery Physiologic Reserve

(Include only for lobectomy, pneumonectomy, or major lung resection.)

• Baseline: FEV₁ [value] ([% predicted]); DLCO [value] ([% predicted])
• Predicted postoperative: ppoFEV₁ [value]; ppoDLCO [value] — Method: [segment counting / perfusion scan / other]
• Exercise testing: [Indicated / performed / not indicated] — [Results if available]
• Physiologic risk conclusion: [Assessment of resection-specific risk]

Assessment

(Problem-oriented list in decreasing clinical severity. Include only applicable problems.)

• Perioperative pulmonary risk: [Overall PPC risk summary with main drivers and key modifiers]
• COPD/Asthma: [Control/stability, recent exacerbations, current regimen and adherence]
• OSA: [Severity, PAP status and adherence, perioperative implications]
• ILD/Restrictive disease: [Stability, oxygen needs, diffusion impairment]
• Chronic respiratory failure: [Baseline support, CO₂ retention risk]
• Pulmonary hypertension: [Severity, RV status, perioperative considerations]
• Active respiratory infection: [Status and treatment course]
• Smoking/vaping: [Current status, readiness to quit]
• Aspiration risk: [Contributing factors and mitigation needs]

Plan

(Frame as risk assessment with recommendations. Avoid stating patient is "cleared.")

Preoperative Optimization

• Smoking cessation: [Counseling provided, quit date goal, support plan]
• Active infection/exacerbation: [Treatment plan; whether to defer elective surgery; criteria for return to baseline]
• Inhaler optimization: [Regimen changes and adherence education]
• OSA management: [Confirm PAP settings, ensure patient brings device, adherence assessment]
• Prehabilitation: [Respiratory muscle training or pulmonary rehab referral if time allows and risk elevated]
• Additional testing: [Recommendations with explicit rationale for how results will change management] OR [No further testing recommended — state explicitly]

Intraoperative Recommendations

• [Anesthesia approach considerations: regional technique preference when appropriate]
• [Bronchodilator availability and trigger avoidance for reactive airway disease]
• [Strategies to minimize residual neuromuscular blockade]

Postoperative Risk Mitigation

• Lung expansion: [Deep breathing exercises, incentive spirometry, CPAP/NIV when indicated]
• Mobilization: [Early ambulation, head-of-bed elevation]
• Medications: [Resume baseline inhalers promptly; PRN bronchodilator plan]
• Oxygen management: [Titration guidance, especially if chronic hypercapnia risk]
• Monitoring/disposition: [Enhanced monitoring or step-down/ICU based on risk]
• OSA precautions: [PAP use, opioid caution, monitoring recommendations]
• Residual risks despite optimization: [Pneumonia, atelectasis, respiratory failure, prolonged ventilation, reintubation as applicable]

Timing/Deferral Guidance

(Include only if acute issues are present.)

• [Recommendation to postpone or proceed with caution, with justification]
• [Criteria for return to optimized baseline and timeframe for reassessment]

Communication and Follow-up

Communication: [How recommendations were communicated: EHR message / phone / in-person discussion]

Follow-up: [Pulmonology will / will not follow postoperatively]; triggers for re-consult: [Specify]

Summary: [Single sentence answering the consult question with risk framing and recommended next steps]