[ Original Research ]

A Randomized Trial of Nebulized

Lignocaine, Lignocaine Spray, or Their
Combination for Topical Anesthesia During
Diagnostic Flexible Bronchoscopy
Sahajal Dhooria, MD, DM; Shivani Chaudhary, MSc; Babu Ram, MSc; Inderpaul Singh Sehgal, MD, DM;
Valliappan Muthu, MD, DM; Kuruswamy Thurai Prasad, MD, DM; Ashutosh N. Aggarwal, MD, DM, FCCP;
and Ritesh Agarwal, MD, DM, FCCP

BACKGROUND: The optimal mode of delivering topical anesthesia during flexible bronchos-
copy remains unknown. This article compares the efficacy and safety of nebulized
lignocaine, lignocaine oropharyngeal spray, or their combination.
METHODS: Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine
(2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine,
group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine
spray (group C). The primary outcome was the subject-rated severity of cough according to a
visual analog scale. The secondary outcomes included bronchoscopist-rated severity of
cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose,
subject’s will- ingness to undergo a repeat procedure, adverse reactions to lignocaine, and
others.
RESULTS: A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The
median (interquartile range) score for subject-rated cough severity was significantly lower in
group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30],
respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P <
.001), and the overall satisfaction was highest in group B (P < .001). The cumulative
lignocaine dose administered was the least in group B (P < .001). A significantly higher
proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group
B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events
were observed.
CONCLUSIONS: Ten actuations of 10% lignocaine oropharyngeal spray were superior to
nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible
bronchoscopy.
TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.
CHEST 2019; -(-):---

KEY WORDS: aerosol; anesthesia; biopsy; bronchoscopy; cough; pain

ABBREVIATIONS: ANOVA = one-way analysis of variance; EBB = FUNDING/SUPPORT: The authors have reported to CHEST that no
endobronchial biopsy; FB = flexible bronchoscopy; IQR = interquartile funding was received for this study.
range; TBLB = transbronchial lung biopsy; VAS = visual analog CORRESPONDENCE TO: Ritesh Agarwal, MD, DM, FCCP,
scale Department of Pulmonary Medicine, Postgraduate Institute of
AFFILIATIONS: From the Department of Pulmonary Medicine, Post- Medical Education and Research, Sector-12, Chandigarh-160012,
graduate Institute of Medical Education and Research, Chandigarh, India; e-mail: agarwal. ritesh@outlook.in
India. Copyright 2019 American College of Chest Physicians. Published
Dr Dhooria and Ms Chaudhary contributed equally to the study and by
should be considered first authors. Elsevier Inc. All rights reserved.

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DOI: https://doi.org/10.1016/j.chest.2019.06.018

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Flexible bronchoscopy (FB) is a commonly performed
procedure in the diagnosis and treatment of several
1
respiratory ailments. Although FB is generally a short
procedure, it is inherently uncomfortable for the
2
patient. The use of sedation and topical anesthesia is
3 8
therefore recommended during FB. Sedative agents
reduce anxiety and pain, and induce anterograde
2 9-15
amnesia. However, due to insufficient capabilities for
postprocedure monitoring, large patient numbers, or
patient preference, the use of sedation may not be
4,5
possible in certain settings. The use of topical
anesthesia during FB is essential, especially when
performed without sedation. Effective topical anesthesia
blunts airway reflexes such as gag, cough, and
2
laryngospasm. The reduction in cough not only
improves patient comfort but also makes the procedure
easier for the operator.
Among agents used for topical anesthesia, lignocaine
is the most widely used drug because of its safety and
favorable pharmacokinetic profile.
3,6,7
Lignocaine is
Subjects and Methods
Setting
This single-center, randomized parallel-group trial was conducted
between June 1, 2017, and June 30, 2018, in the bronchoscopy suite
of the Postgraduate Institute of Medical Education and Research.
The study protocol was approved by the Ethics Review Committee
(Ref. No. NK/3405/Res/837), and written informed consent was
obtained from all study participants. The trial was registered at
clinicaltrials.gov.16
In our bronchoscopy suite, most of the FB procedures, including
airway examination, BAL, bronchial toileting, endobronchial biopsy
(EBB), and transbronchial lung biopsy (TBLB), are performed under
topical anesthesia without the use of sedation.17 Most of the
diagnostic bronchoscopy procedures are performed by fellows under
direct supervision of consultants. Procedures such as transbronchial
needle aspiration (conventional or endobronchial ultrasound-guided),
tumor ablation (using laser or argon plasma coagulation), and other
interventional pulmonology procedures are performed under sedation.
Subjects
Consecutive subjects aged $ 18 years undergoing FB without
sedation were included in the study. Subjects with any of the
following were
excluded: (1) planned for any FB procedure under sedation; (2)
known hypersensitivity to lignocaine; (3) hemodynamic instability;
(4) baseline hypoxemia (blood oxygen saturation < 92% on room
air); (5) pregnancy; (6) comorbid illness such as heart failure,
chronic kidney disease, or chronic liver disease; and (7) failure to
provide informed consent.
Randomization
Subjects were randomized 1:1:1 to one of the three groups by using the
block randomization method with blocks of 10. The randomization
sequence was computer generated, and the assignments were placed
in opaque sealed envelopes. The study subjects were not blinded; the
3 chestjournal.o
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available in various formulations (gel or solution) and
can be delivered to the respiratory passages by using
different modes (spray, nebulization, transtracheal
injection, bronchoscopic instillation, and others).
Nebulization is often considered a safe and convenient
way of delivering drugs to the respiratory tract.
Several studies have described the use of nebulized
lignocaine for topical anesthesia during FB.
However, most of these studies had small sample sizes
and different protocols, and all of them involved the
use of sedation. To the best of our knowledge, there is
no large head-to-head comparison of nebulized
lignocaine with oropharyngeal lignocaine spray and
their combination. We hypothesized that a
combination of nebulized and sprayed lignocaine
would be the most effective method in achieving
topical anesthesia. The current study compares the
efficacy and safety of nebulized lignocaine,
oropharyngeal lignocaine spray, and their
combination for topical anesthesia in subjects
undergoing diagnostic FB.
bronchoscopist and the assessor of outcomes were blinded to the
group allocation.
Study Protocol
The subjects presented to the bronchoscopy suite after an overnight
fast. Subjects in group A underwent nebulization with 2.5 mL of
4% lignocaine (Lox, 42.7 mg/mL; Neon Laboratories) for 15 min by
using a jet nebulizer (Omron Healthcare). In group B, nebulization
was not performed; lignocaine spray solution (10%, Lox, 100
mg/mL; Neon Laboratories) was sprayed 10 times (10 mg/puff) in
the oropharynx at 5-s intervals. In group C, both nebulization and
spray were performed in the aforementioned fashion with the
only difference being that two sprays were administered in this
group instead of 10. The local anesthesia was administered in a
separate pre-bronchoscopy area by a study nurse not involved
in data collection and analysis.
Following this initial preparation, approximately 5 mL of lignocaine
gel (2%; Neon Laboratories) containing 100 mg of lignocaine was
applied to the nasal cavity, and the bronchoscope was
introduced. Four aliquots of 2 mL of 1% lignocaine solution
(Wocaine; Wockhardt Ltd.) were administered, one each to the
vocal cords, carina, and both the main bronchi, through the
bronchoscope using the “spray-
18
as-you-go” technique. The standard dose administered in each
group was calculated as follows: group A, 291.95 mg (2.5 mL of
4% nebulized lignocaine [106.75 mg] plus 5 mL of 2% lignocaine gel
[100 mg] plus 8 mL of 1% lignocaine [85.2 mg]); group B, 285.2 mg
(10 puffs of 10% lignocaine spray [100 mg] plus 5 mL of
2% lignocaine gel [100 mg] plus 8 mL of 1% lignocaine [85.2 mg]);
and group C, 311.95 mg (2.5 mL of 4% nebulized lignocaine
[106.75 mg] plus 2 puffs of 10% lignocaine spray [20 mg] plus 5 mL
of 2% lignocaine gel [100 mg] plus 8 mL of 1% lignocaine [85.2
mg]).
Additional aliquots of lignocaine (2 mL of 1% lignocaine) were given
at the operator’s discretion as rescue treatment to suppress cough.
The number of additional aliquots administered was recorded.
We
[ - # - CH E S T - 2 3
 recorded the cumulative (standard and rescue treatment) doses of
lignocaine administered to each subject. Subjects were monitored for
3 h postprocedure to assess for any adverse effects related to
lignocaine use (arrhythmia, convulsions, involuntary movements,
bronchospasm, and anaphylaxis).
Immediately after the bronchoscopy, the subjects rated their perception
of the severity of cough during the procedure on a visual analog
scale (VAS). The VAS score for cough was marked on a horizontal
line,
100 mm in length, with “no cough” at one end (score, 0) and “worst
cough” at the other (score, 100).19 Subjects also recorded their
perception of pain during the procedure on the Faces Pain Rating
scale. The scale comprises six faces with brief instructions provided
with the scale and a numerical rating (from 0-10) assigned to each
20
face. The bronchoscopist (operator) also documented his or her
perception of the subject’s severity of cough and the overall
satisfaction with the procedure on a VAS anchored between
unsatisfactory (score 0) to highly satisfactory (score 100).
Study Outcomes
The primary outcome of the study was the severity of cough rated by
the subject on the VAS. The secondary outcome measures included: (1)
operator-rated severity of cough on the VAS; (2) pain during the
procedure rated by the subjects on the Faces Pain Rating Scale; (3)
overall satisfaction with the procedure rated by the operator on the
VAS; (4) cumulative dose of lignocaine administered during the
procedure; (5) changes in vital parameters (heart rate and oxygen
saturation) during and following the procedure; (6) duration of the
procedure; (7) time taken to cross the vocal cords; (8) willingness of
the subject to undergo a repeat procedure; and (9) adverse reactions
to lignocaine.
We performed a post hoc analysis in which we compared: (1) the
subject-rated severity of cough on a VAS among subjects who
Results
Of the 1,713 subjects screened, 1,050 (350 in each
group; 64.8% men) with a median (IQR) age of 51 (36-
62) years, were included in the study (Fig 1). A total
of
284 subjects underwent procedures under sedation
(250, convex-probe endobronchial ultrasound; 16,
radial endobronchial ultrasound; nine, conventional
transbronchial needle aspiration; and nine, other
interventional procedures [electrocautery, argon
plasma coagulation, laser, and others]) and were
excluded. The baseline characteristics were similar in
the study groups (Table 1) except there were
significantly more men in group B, and the median
heart rate before the procedure was significantly lower
in group C. The most common indication for
bronchoscopy was suspected respiratory infection
(51.0%) followed by malignancy (23.5%). The
commonly performed procedures included BAL
followed by EBB. Airway inspection alone was
performed in 23% of the study subjects. Of the 1,050
procedures, 90 were performed solely by the
consultants, and the remaining procedures were
performed by fellows supervised by the consultants.
4 chestjournal.o
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underwent biopsy (EBB or TBLB) in group B vs the other groups;
and (2) the subject-rated severity of cough on a VAS in subjects in
group B who underwent biopsy (EBB or TBLB) vs those who did
not; (3) the effect of the operator (consultant or fellow) on the
subject-rated severity of cough; and (4) the diagnostic yield of the
biopsy procedures.
Sample Size Calculation
The sample size was calculated by assuming an effect size of 0.1 for
the difference in means of the primary outcome (G*Power,
version
3.1.9.2).18 At a power of 80% and a significance level of 0.05, we
estimated that 969 patients were required in total to estimate the
difference between the three groups, using one-way analysis of
variance (ANOVA) with fixed effects. We aimed at recruiting at least
1,000 subjects into the study.
Statistical Analysis
The commercial statistical package SPSS for MS Windows version
22 (IBM SPSS Statistics, IBM Corporation) was used for
performing all statistical analyses. Data are presented in a
descriptive fashion as number with percentage or median with
interquartile range (IQR). The c 2 (or Fisher exact test) was used
to analyze categorical variables. A Kruskal-Wallis ANOVA was
used for comparing continuous data. A two-way ANOVA was
performed, with the primary outcome as the dependent variable,
to analyze the interaction between the study groups and the
operator (consultant or fellow). The Spearman coefficient was
calculated for the correlation between subject-rated and operator-
rated severity of cough. The changes in variables before, during,
and after the procedure were analyzed with multiple repeated
measures ANOVA. A P value < .05 was considered statistically
significant.
Primary Outcome
The median (IQR) score for the subject-rated severity of
cough on VAS (Table 2) was significantly lower in
group B compared with group C and group A (4 [1-
10] vs 11 [4-24] and 13 [5-30], respectively; P < .001
for both the comparisons), whereas there was no
difference between groups A and C (P ¼ .09). The
difference in the primary outcome remained significant
in group B vs the other groups among subjects who
underwent EBB or TBLB
(P < .001). There was, however, no difference in the
subject-rated severity of cough on VAS among the
subjects in group B alone who underwent biopsy (EBB
or TBLB) vs those who did not (P ¼ .47). The
difference in the primary outcome between the study
groups was similar (P ¼ .54), irrespective of the
operator (consultant or a fellow).
Secondary Outcomes
The intensity of the subject’s cough rated by the
operator on VAS was also the least in group B, followed
by group C and group A (7 [2-20] vs 13 [6-27] and 16
[7-34], respectively; P < .001). There was a significant
correlation between subject-rated and operator-rated
[ - # - CH E S T - 2 4
 1,713 subjects screened for eligibility
Enrollme
Allocati
Group A: Nebulization only
n = 350
Analys
Excluded from analysis
n=0
Figure 1 – Consolidated Standards of Reporting Trials diagram demonstrating the flow of participants in the study.
severity of cough (Spearman coefficient ¼ 0.60; P <
.001). The pain experienced during the procedure was
similar in the three groups (P ¼ .08). The median (IQR)
VAS score for overall satisfaction with the procedure
rated by the operator was significantly higher in group
B (88 [74-96]) compared with group C (82 [68-90]; P
< bronchospasm, involuntary movements, or convulsions
.001) and group A (79 [63-92]; P ¼ .016), whereas there
was no difference between groups A and C (P ¼ .40).
The median cumulative dose of lignocaine administered
was the least in group B (285 mg) followed by group A
(292 mg) and group C (312 mg). The highest dose of
lignocaine used in any of the groups was 420 mg. A
significantly higher proportion of subjects (P < .001)
were willing to undergo a repeat bronchoscopy in group
B (73.7%) than in group A (49.1%) and group C
(59.4%). The median time to cross the vocal cords was
the least in group B, and the total procedure duration
did not differ between the three groups. The median
(IQR) duration of the procedure in the group of subjects
who underwent biopsies (EBB and/or TBLB) was 8 (6-
11) min, and it was 4 (3-5) min in those who underwent
procedures such as airway inspection or BAL.
There was a significant increase in heart rate during the
procedure (P < .001) and a significant reduction (P <
.001) following the procedure in all the study groups;
however, the change in heart rate was similar across the
5 chestjournal.o
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663 subjects excluded
284 Underwent procedures under sedation
147 Hypoxemia
105 Refused consent
87 Hemodynamically unstable
40 Comorbidities
1,050 randomized
Group B: Spray only Group C: Nebulization plus
n = 350 spray n = 350
Excluded from analysis Excluded from analysis
n=0 n=0
groups (P ¼ .41). There was a significant drop in
oxygen saturation during the procedure (P < .001) and
a significant increase after the procedure (P ¼ .01);
however, the change in oxygen saturation was similar
across the study groups (P ¼ .25). No adverse events
related to lignocaine such as arrhythmias,
were observed in any patient.
We also explored the diagnostic yield of EBBs and
TBLBs in the study groups. The diagnostic yield of
EBB was significantly higher (P ¼ .02) in group B than
in the other groups, whereas that of TBLB was similar
in the three groups (Table 2).
Discussion
The results of this large study suggest that the use of 10
puffs of oropharyngeal spray of 10% lignocaine prior to
FB provided superior topical anesthesia and highest
operator satisfaction compared with nebulized
lignocaine or their combination. Moreover, this outcome
was achieved at a marginally lower dose of lignocaine.
A patient-reported outcome, the severity of cough on a
VAS, was chosen as the overall measure of topical
anesthesia because it is the most distressing symptom
that needs to be adequately controlled during the
procedure.
[ - # - CH E S T - 2 5
 TABLE 1 ] Baseline Characteristics of the Study Population
Characteristic Group A (n ¼ 350) Group B (n ¼ 350) Group C (n ¼ 350) Total (N ¼ 1,050) P Value
Demographic variables
Male, No. (%) 215 (61.4) 249 (71.1) 216 (61.7) 680 (64.8) .009
Age, y 52 (35-62) 52 (37-61) 50 (36-63) 51 (36-62) .96
Current smokers, No. (%) 109 (31.1) 126 (36.0) 107 (30.6) 342 (32.6) .24
Indication for bronchoscopy, No. (%) .48
Respiratory infection 174 (49.6) 171 (48.9) 190 (54.3) 535 (51.0)
Malignancy involving lung 80 (22.9) 91 (26.0) 76 (21.7) 247 (23.5)
Hemoptysis 50 (14.3) 35 (10.0) 33 (9.4) 118 (11.2)
Diffuse lung disease 9 (2.6) 11 (3.1) 10 (2.9) 30 (2.9)
Others 37 (10.6) 42 (12.0) 41 (11.7) 120 (11.4)
Physiological parameters
Heart rate, beats/min 88 (84-92) 88 (84-92) 86 (82-92) 88 (84-92) .03
a
Oxygen saturation, % 98 (97-98) 98 (97-98) 98 (97-98) 98 (97-98) .23
b
Procedures performed, No. (%)
Airway inspection only 79 (22.6) 77 (22.0) 85 (24.3) 241 (23.0) .76
BAL 207 (59.1) 205 (58.6) 209 (59.7) 621 (59.1) .95
Endobronchial biopsy 74 (21.1) 81 (23.2) 70 (20.0) 225 (21.4) .58
Transbronchial lung biopsy 34 (9.7) 29 (8.3) 35 (10.0) 98 (9.3) .71
Foreign body removal 0 2 (0.6) 0 2 (0.2) .14

Data are presented as median with interquartile range, unless otherwise indicated.
a
Oxygen saturation at baseline, on room air, immediately prior to the procedure.
b
More than one procedure performed in several patients.

Although the subject-rated severity of cough on VAS
was significantly lower with the use of lignocaine
oropharyngeal spray (10 actuations), the actual
numerical difference in the score for cough was not
very large between the groups. However, the consistent
superiority of sprayed lignocaine across all primary and
the secondary outcomes indicates that it was indeed
more effective than the other two modalities studied.
yield of biopsy procedures (EBB and TBLB) in the study
groups. Interestingly, the diagnostic yield of EBB was
significantly higher in the sprayed lignocaine group
compared with the other groups. The better cough
control in the sprayed lignocaine group possibly made
the procedure more convenient for the biopsy. However,
the diagnostic yield of TBLB was similar in the three
groups and comparable to published literature.
22

This finding is also supported by the fact that there was

a marked difference in the patient’s willingness to
repeat the procedure in the sprayed lignocaine group
(74%)
vs the nebulized and combination groups (49% and
59%,
respectively). Lignocaine sprayed over the oropharynx
spreads over the lateral and posterior pharyngeal walls,
21
the soft palate, and the uvula. This not only abolishes
the gag reflex but also allows a convenient passage of
the
bronchoscope until the level of the vocal cords, where
lignocaine can then be delivered with bronchoscopic
instillation (spray-as-you-go technique).
It is noteworthy that only 21.4% and 9.3% of the study
subjects underwent EBB and TBLB, respectively. Even
among the subjects who underwent biopsies, the control
of cough was the best in group B. Although not a
predefined outcome, we also explored the diagnostic
Early nonrandomized studies on the use of nebulized
lignocaine during bronchoscopy found it to be an
effective and acceptable means of delivering topical
23,24
anesthesia to the respiratory tract. What, then, is the
possible reason for the apparent lack of efficacy of
nebulized lignocaine in previous randomized trials9-15
and the current study (despite a similar dose
administered by nebulization and spray)? Nebulized
lignocaine spreads extensively in the form of an aerosol
over the surface of the mucosa of the entire respiratory
tract (nose, mouth, pharynx, vocal cords, trachea, and
11
bronchi). However, as with all aerosols, the proportion
of the drug actually reaching the intended site is not
25
only small but also variable. A more direct mode of
delivering lignocaine to the different regions of the
respiratory passages (namely, as a gel to the nose, spray

6 chestjournal.o
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TABLE 2 ] Primary, Secondary, and Exploratory Outcomes of the Study
Outcome Group A (n ¼ 350) Group B (n ¼ 350) Group C (n ¼ 350) P Value
Primary outcome
a
Patient-rated VAS score for cough 13 (5-30) 4 (1-10) 11 (4-24) < .001
Secondary outcomes
a,b
Operator-rated VAS score for cough 16 (7-34) 7 (2-20) 13 (6-27) < .001
Faces Pain Rating Scale 0 (0-0) 0 (0-0) 0 (0-0) .08
a
Operator-rated VAS score for overall 79 (63-92) 88 (74-96) 82 (68-90) < .001
satisfaction
Lignocaine
a,b
Cumulative administered dose, mg 292 (292-292) 285 (285-285) 312 (312-312) < .001
Range, mg 292-420 285-349 312-376
Heart rate during procedure, beats/minute 120 (112-125) 120 (108-124) 118 (108-124) .09
Heart rate after procedure, beats/min 94 (92-98) 92 (90-98) 92 (90-98) .29
Oxygen saturation during procedure, 96 (95-97) 96 (95-97) 96 (95-97) .37
beats/min
Oxygen saturation following the procedure, 96 (95-97) 97 (95-97) 96 (95-97) .15
beats/min
Procedure duration, min 5 (4-7) 5 (4-7) 5 (4-7) .18
a
Time to cross the vocal cords, s 25 (21-34) 20 (17-26) 24 (20-32) < .001
a,b
Willingness to repeat the procedure, No. (%) 172 (49.1) 258 (73.7) 208 (59.4) < .001
Exploratory outcomes
Diagnostic yield, n/N (%)
Endobronchial biopsy 57/74 (77.0) 75/81 (92.6) 61/70 (87.1) .02
Transbronchial biopsy 18/34 (52.9) 15/29 (51.7) 20/35 (57.1) .89

Data are presented as median (interquartile range), unless otherwise indicated. VAS ¼ visual analog scale.
a
Significant difference between groups A and B, and groups B and C.
b
Significant difference between groups A and C.

to the oropharynx, and bronchoscopic instillation of
lignocaine solution to the vocal cords, trachea and the
bronchi) is probably more effective. It may also nullify
any additional effect of minute quantities of the
lignocaine aerosol reaching these regions of the airway
through nebulization, as in the combination group.
Most guidelines recommend the use of IV sedation
3,7
while performing FB. However, due to the
equivalent safety of FB with or without sedation, the
practice of no-sedation bronchoscopy is not
4,5,26
uncommon. We believe that sedation should be
routinely used during FB to enhance patient comfort.
We do not intend to endorse the practice of no-
sedation bronchoscopy. Unfortunately, at our center,
due to logistic difficulties, procedures such as airway
inspection, BAL, EBB, and TBLB are performed under
local anesthesia alone without the use of sedation.
Incidentally, bronchoscopy performed without
sedation, as in the current study, offered a better
setting to study the true efficacy of topical anesthesia,
as minor differences between various modalities in
terms of cough suppression are likely to be better
appreciated by an awake patient.
What are the clinical implications of the current
study? The American College of Chest Physicians
consensus statement on the use of topical anesthesia,
analgesia, and sedation during FB does not make any
clear recommendation on the use of nebulized
3
lignocaine or lignocaine oropharyngeal spray.
Conversely, the British Thoracic Society guideline for
diagnostic bronchoscopy makes a grade B
recommendation against the use of nebulized
7
lignocaine. Our study clearly showed the superiority
of 10 puffs of 10% spray over nebulized lignocaine or
their combination (with two sprays) during FB. We
also did not encounter any adverse effects of
lignocaine. We believe that future guidelines should
recommend 10 actuations of 10% lignocaine spray
rather than nebulized lignocaine or their combination
along with the spray-as-you-go technique (for the

7 chestjournal.o
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 tracheobronchial tree) for topical anesthesia during
FB.
The current study has a few limitations. We used 10
actuations of 10% lignocaine; whether a lesser number of
actuations (5-9) are also effective remains unknown. The
study subjects were not blinded to the study groups,
although the other involved personnel were blinded.
Several bronchoscopists performed the procedures;
however, the consistency of the results across outcomes
despite multiple operators possibly makes the
generalization to real-world settings reasonable.
However, it should be noted that we excluded subjects
with baseline hypoxemia and those with comorbidities,
including heart failure, chronic kidney, and liver
disease. We also did not record the presence of
comorbidities such as coronary artery disease and
COPD, or the use of opioids and benzodiazepines
among our study subjects. Finally, we did not measure
the plasma levels of lignocaine.
Conclusions
The results of this study suggest that the use of 10
actuations of 10% lignocaine spray delivered to the
oropharynx resulted in superior topical anesthesia
compared with nebulized lignocaine or their
combination during diagnostic FB.

Acknowledgments
Author contributions: R. A. is the
guarantor of the paper, taking responsibility
for the integrity of the work, from inception
to published article. R. A. conceived the idea,
was involved in patient management, and
drafted and revised the manuscript; S. D. was
involved in patient management and data
collection, and drafted and revised the
manuscript; S. C. and B. R. were involved in
patient management and data collection, and
drafted the manuscript; and I. S. S., V. M., K.
T. P., and A. N. A. were involved in patient
management and revised the manuscript.
Financial/nonfinancial disclosures: None
declared.
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