www.markacruzdds.com - Pediatric Airway Assessment

  • Pediatric Airway Assessment

    This screening form may help identify patients at increased risk for sleep-related breathing disorders (e.g., obstructive sleep apnea) and/or breathing complications when undergoing sedation or general anesthesia. Such patients may benefit from referral to a medical professional for further evaluation and management.

  • Part I. General History

  • Was your child born prematurely?*
  • Does your child have a craniofacial syndrome?*

  • Does your child have any history of

  • A physical or neurological impairment?*
  • Low muscle tone?*
  • Respiratory disease/breathing problems?*
  • Repeated exposure to smoke?*

  • Part II. Daytime indicators

    Does your child often:
  • Tend to breathe through the mouth?*
  • Wake up with headaches in the morning?*
  • Seem restless, unable to sit still, or always on the go?*
  • Interrupt others, have difficulty staying focused, or become easily frustrated?*
  • Do you or a teacher notice your child appears sleepy during the day?*

  • Part III. Sleep History

  • How would you rate your child’s sleep?

  • Does your child

  • Fall asleep quickly?*
  • Snore more than half the time while sleeping?*
  • Snore loudly while sleeping?*
  • Have trouble breathing or struggle to breathe while asleep?*
  • Stop breathing during sleep?*
  • Grind his/her teeth while sleeping?*
  • Sleep in a seated position or with neck hyperextended?*
  • Occasionally wet the bed at night?*
  • Experience excessive sweating while sleeping?*
  • Is your child hard to wake up in the morning?*
  • Date*
     - -
  • Which Modified Mallampati Classification1 best describes the patient?
  • Image field 110
  • Which tonsillar grade1 (adapted) best describes the patient?
  • Image field 112
  • Is a medical referral indicated?*

  • Reference:

    1. Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope 1999;109(12):1901-7.

  • Images reprinted and adapted with permission of John Wiley and Sons.
    Copyright © 1999. Friedman M, Tanyeri H, La Rosa M, Landsberg R, et al. Laryngoscope 1999;109(12):1901-7.
    Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1097/00005537-199912000-000028”.
    Laryngoscope is published for the American Laryngological Rhinological and Otological Society by John Wiley and Sons Ltd.

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