In this study, researchers compared outcomes associated with the use of nebulized lignocaine, lignocaine oropharyngeal spray, or a combination of the two when delivering topical anesthesia during flexible bronchoscopy. Final analysis included 1,050 consecutive patients (median age, 51 years; 64.8% were male) who 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 cough severity, as rated by the patient using a visual analog scale; secondary outcomes were cough severity and overall procedural satisfaction as rated by the bronchoscopist, total lignocaine dose, whether the patient would undergo the procedure again, and adverse reactions to lignocaine. The median patient-rated cough severity was 4 in group B, compared to 11 and 13 in groups C and A, respectively (P<0.001 for all). Group B also had the lowest bronchoscopist-rated cough severity and highest overall satisfaction (P<0.001 for both). Group B had the least cumulative lignocaine dose administered (P<0.001). When asked whether they would undergo the procedure again, 73.7% of patients in group B said they would, compared to 59.4% and 49.1% in groups C and A, respectively. There were no reported adverse events related to lignocaine.