(I) Introduction Wang Xiaoping, Department of Respiratory Medicine, Shandong Chest Hospital With the leaping development of interventional pulmonology, various techniques of bronchoscopy have been irreplaceable in the diagnosis and treatment of respiratory diseases. Bronchoscopic operation will inevitably cause unsuitable pain for patients, and whether or not the preoperative anesthesia for bronchoscopy is ideal directly affects the operation and diagnostic and therapeutic effects. Currently, there are three types of anesthesia related to bronchoscopy: local anesthesia, local anesthesia combined with intravenous sedation, analgesia (i.e., the so-called painless bronchoscopy technique), and general anesthesia. In this issue, we will first introduce the first article of local anesthesia. I. Overview Local anesthesia is the application of local anesthetic drugs to temporarily block the nerve conduction in a region of the body to produce anesthesia. Local anesthesia is administered when the patient is awake, easy to operate, little interference with physiological function, safer, less complications, used in most small and medium-sized surgery. Local anesthesia methods include spray method, endotracheal drip method, gargling method, ring plus membrane puncture method. Second, anesthesia drugs Commonly used anesthesia drugs are 2% lidocaine. The total dosage of adult lidocaine is generally no more than 25 ml, and the dosage should be reduced for elderly patients and patients with cardiac and hepatic function impairment. In addition, after achieving the expected anesthetic effect, the use of lidocaine should be reduced. Third, local anesthesia methods 1. Spray anesthesia of the pharynx: 2% lidocaine throat spray, spray every 2-3 minutes, each spray 3-5 sprays. The anesthesia effect is poor, the need for anesthesia drugs is large, affecting the success rate of insertion, easy to appear nausea and other side effects. And need to be in the bronchoscope into additional anesthesia drugs. 2. endotracheal drip method: in the nasopharyngeal anesthesia based on the syringe connected to a diameter of about 2mm plastic tube, about 15cm long, inserted by the nasal cavity, so that the patient deep breathing, injected into the lidocaine 2 times, each time about 2 ml, anesthesia drug through the pharyngeal part of the inflow of the vocal folds in order to play the anesthesia of the most. 3. gargle method: is currently rarely used. Generally use 1% bupivacaine solution, tilt the head and gargle 2-3 times, each time about 1min. 4. ultrasonic nebulization: 2% lidocaine 30ml into the nebulizer bottle, the nozzle is placed in the middle of the oral cavity, from the pharynx at 1.5cm, for the mouth inhalation and nasal breathing for 10min or so, breathing deep and long effect is better, in order to make the nose, pharynx, trachea and bronchi mucous membranes to obtain full anesthesia. This method is simple and easy for patients to accept. Cricothyroid puncture anesthesia: It is the best method of surface anesthesia for the mucous membrane of the lower respiratory tract, which achieves effective anesthesia in a short period of time and with a small dosage. However, it cannot cover the anesthesia of oropharynx and nasal cavity, and can be used in combination with gargle method and spray method. At present, our department adopts the local anesthesia method of spray combined with cricothyroid puncture. Operation steps 1. Positioning: the patient lies supine, head tilted back, probe the midline of the thyroid cartilage, and touch a depression and another hard structure downward, i.e. the cricothyroid fossa and the cricoid cartilage, and there is a cricothyroid membrane covering the cricothyroid fossa between the cricothyroid cartilage and the cricoid cartilage, which is the site of the injection. 2. Disinfection (① in the following figure): disinfect the iodine swab from the inside to the outside for three times, with a diameter of about 3cm. 3. Confirm the puncture site once again (② in the following figure). 4. 4. Fix the patient’s cricothyroid fossa with the left hand and tell him not to cough as much as possible. Enter the needle vertically with the right hand and withdraw the core back after a breakthrough sensation, and air can be sure to reach the injection site. (Figure ③ below) 5. Inject 3-5 ml of 2% lidocaine and withdraw the needle quickly. (Picture ④ below) 6. Help the patient to do up coughing, which is conducive to the full diffusion of anesthetic drugs. （With the continuous progress and development of medicine, it has become the common pursuit of clinicians and patients to let patients undergo medical examination and treatment in a safe and painless state. Here we need to introduce the concept of monitored anesthesia, which refers to the anesthesiologist’s participation in local anesthesia patients and monitoring and/or the use of sedative-analgesic drugs for patients undergoing diagnostic or therapeutic operations, in order to alleviate the patient’s anxiety and fear, strengthen the pain and other injuries a few times, and improve the perioperative period of safety and comfort. Second, the advantages of local anesthesia + monitoring anesthesia in bronchoscopy in bronchoscopy interventional therapy in the examination process of applying a certain amount of intravenous sedative and analgesic drugs so that the patient has a certain amount of transient sleep process, after the completion of the examination and treatment, the patient can quickly wake up, no memory of the whole process of the examination, no feeling of pain, to avoid the patient’s local anesthesia physiological and psychological discomfort, is conducive to improving the effectiveness of the examination and the rate of re-examination Third, when bronchoscopy is operated, the patient can feel no pain and no memory. Third, the choice of sedative and analgesic drugs during bronchoscopy operation Commonly used drugs are opioid analgesic fentanyl and its family, neuroleptic sedative midazolam, intravenous anesthesia isoproterenol and etomidate. Midazolam: sedative-hypnotic effect, with anxiolytic effect, can make the patient sedated, attention reduced, forget the examination process, thus improving patient tolerance, reduce stress reaction. Fentanyl: strong analgesia, respiratory depression, fast onset of action, and other characteristics. It can increase tolerance to respiratory manipulation. Pharmacologically, midazolam and fentanyl can synergize and complement each other to maintain the stability of the circulatory and respiratory systems. Isoproterenol: the most commonly used intravenous anesthetic with fast onset, short duration and no analgesic effect, it is considered to be the most widely used anesthetic drug in bronchoscopy and treatment at present; however, since its main efficacy is sedation, it generally needs to be combined with other analgesic drugs. Etomidate: a fast-acting sedative-hypnotic drug with better vascular tolerance, more suitable for induction and maintenance of general anesthesia in patients with cardiovascular instability. Local anesthesia combined with intravenous sedation and analgesia bronchial examination indications: as long as the patients are eligible for tracheoscopy can be implemented local anesthesia combined with intravenous sedation and analgesia, especially suitable for the following patients: infants and young children or patients with psychological fear. The pharynx is particularly sensitive and the airway is highly reactive. Patients who anticipate a prolonged bronchoscopic maneuver. Require more complex bronchoscopic maneuvers. Other patients who cannot cooperate. The operator is an unskilled beginner. Methods of operation: local mucosal surface anesthesia before the operation, the patient took the supine position, the head was positioned correctly, and oxygen was inhaled. Routine monitoring of SpO2, BP, ECG, respiration, equipped with relevant rescue equipment and drugs. Intravenous slow push midazolam 0.05mg/kg and fentanyl 1-2ug/kg, can also be used in small doses of isoproterenol or etomidate push and pump maintenance. The patient is operated after entering the sedation state, when the patient occurs respiratory depression, hypoxemia, tongue back fall, etc. After the patient can be used to increase the flow rate, elevation of the jaw, simple respirator artificial respiration and other methods of rescue. General anesthesia that is, after the induction of intravenous general anesthesia, using a variety of short-acting intravenous anesthetics composite application, intermittent or continuous intravenous maintenance of anesthesia method. (Continued)