Objectives: To establish an optimized airway management process to improve preoperative lung dysfunction in obstructive sleep apnea (OSA). Design: A retrospective case series study Setting: Tertiary university hospital in China Participants: The study included 483 children (319 males and 164 females; 6y to14y years) with OSA who underwent an adenotonsillectomy from November 2017 to December 2018. Main outcome measures: Children with OSA and who had abnormal airway function were identified by lung function test, and the risk factors for abnormal lung function were assessed. Next, the children received individualized atomization intervention based on the severity of their abnormal lung function, and the improvement in lung function was evaluated. Results: Lung function tests revealed that 45 patients had obstructive ventilation dysfunction, and histories of chronic cough or asthma were identified as risk factors for perioperative abnormal lung function. The FEV1% pre exceeded 80% after 2 days of atomization intervention in 27 of 28 mild cases, 4 of 13 moderate cases, but in none of the 4 moderate-severe cases. After 4 days of atomization intervention, the FEV1%pre of the remaining 14 patients in the three groups all increased up to 80%. Other indicators of lung function (e.g., FEV1/FVC% pre, MEF50% pre, MEF25% pre, and MMEF% pre) were also greatly improved following the improvement of FEV1% pre. No perioperative airway complications occurred. Conclusion: Prior to performing surgery on children with OSA and who have risk factors associated with abnormal lung function, it is potentially beneficial to establish an optimized airway management process to improve lung function before adenotonsillectomy. Keywords: Children, obstructive sleep apnea, airway management, lung function, surgical risk