The preanesthesia evaluation is an opportunity to elucidate the patient’s underlying medical disease, determine if the patient is optimized, treat modifiable conditions, screen for potentially unrecognized disorders, and assess overall risk for perioperative complications. In this chapter, we present the principles of a thorough preoperative assessment and preoperative optimization plan for interventional pulmonology (IP) patients. IP procedures are never truly elective procedures, and patients deemed too high risk to undergo thoracic surgery may be offered an IP procedure as a lower risk “nonsurgical” alternative diagnostic or therapeutic intervention. While IP procedures are less invasive than surgery, the inherent risks of general anesthesia and the implications of a shared and/or difficult airway need to be taken into account, especially in a patient population with pulmonary disease. We will cover the general principles of preoperative assessment with a specific emphasis on optimizing patients with pulmonary disease. We will also detail the components of a thorough airway exam and discuss how to utilize this assessment to create a safe IP anesthetic plan.