It depends of differents aspects as child age and type of procedure we can espect in advance. If we can anticipate need work at any time with rigid bronchoscope we prefer general anesthesya and relaxation

I fully agree with your analysis.

After visiting several centers of excellence in Bronchology in Italy and Europe, I can say that there is no accurate guideline in this regard.

It would be in my opinion very important to uniform strategies in order to obtain a useful tool to provide a shared anesthesiologic strategie.

For example, in our center (Monaldi Hospital in Naples) we use local anesthesia, in all fibro diagnostic bronchoscopy in adult quiet patients .

In all cases in which the patient is agitated, we usually prefer to perform a deep sedation with assistance of the anesthesiologist.

In all rigid bronchoscopy and in all interventional procedures we use a deep sedation.

For TBNA, if the patient is calm, we prefer a good local sedation.

But in my opinion it would be essential to standardize the procedures for anesthesia in the various procedures used in Bronchology.

It is very important that the team of Bronchology choose which procedure to use in any case: from local anesthesia to general anesthesia. Many times a good coverage with topical anesthesia also allows investigations in complex patients.

As Dr. Cesaro pointed out, there is no uniform standard of anaesthetic procedures to facilitate bronchoscopy. Of course, the type of anaesthesia will depend on the complexity of the procedure planned: While in simple bronchoscopic inspection or lavage, local anaesthesia will be sufficient, difficult biopsies / EBUS / interventional procedures will require adequate sedation. We are quite happy with a combination of 2-5 mg Midazolam as a starter (good for decreasing anxiety, amnesia is helpful, too) with repeated bolus administration of proposal. Our patients are very satisfied with the quality of sedation, whereas we are often told about uncomfortable experiences in other centers. However, when using this kind of sedation, it is absolutely necessary to have experienced personnel administering the sedation as the margin between optimal sedation and the beginning of ventilatory depression isn't too wide.

In addition, there are a lot of aspects to discuss. For example, in Germany several well-renowned bronchoscopy centers advise to perform EBUS under all circumstances under general anesthesia to obtain adequate quality. We do not follow this advice due to the high amount of resources necessary for such a strategy.

To conclude: For every setting (expericence of personnel, type of patient population, infrastructure regarding the immedate follow up, and so on) there will be a "perfect" set of anesthesia standards. I believe that it is more important to identify this optimal set of prodecures locally than trying to create universally applicable standards.

In India also most of the bronchoscopist made their own way ahile performing bronchoscope. In the big hospitals here anesthetist most of the time remained available during the procedure, otherwise bronchoscopist with his or her assistant did the job.

For pediatric bronchoscopic procedure mainly for the diagnostic purposes we use desmedetomidine or propofol and everything been decided like dose, drugs as per the respones of the child. But for the children below the age of 4-5 years we prefer to go for general anesthesia especially for therapeutic bronchoscopic procedures.

For adults we use midazolam and local lignocaine gurgling, lignocaine spray and lignocaine injections especially before enetring the vocal cord, after entering the trachea, RMB and LMB. But sometimes fentanyl or desmedetomidine are also needed. Everything is decided based on the response of the patient and length of the procedures.

I work as an anesthesiologist at Ospedale Maggiore - Italy, where several EBUS-TBNA procedures are performed every year. In this case we have adopted a deep sedation/general anesthesia using TIVa (propofol + remifentanil) and laryngeal mask with spontaneous breathing. The results are very good in terms of quality for bronchoscopist and for patients.

Propofol. Propofol (2,6-diisopropylphenol) is a short-acting anaesthetic agent with a rapid onset of action that has been used in bronchoscopy for moderate sedation.