The patient’s respiratory and cardiovascular status should be optimised before the procedure. This may include chest physiotherapy, bronchodilators, antibiotics and corticosteroids for patients with chronic obstructive pulmonary disease. Current medications are usually continued except for anticoagulant medications. The role of preoperative medication has not been studied prospectively in randomised trials. Some authors administer atropine 0.4–0.8 mg prior to the procedure to prevent vasovagal reactions (Rodriguez-Panadero et al. 2006; Mathur et al. 1995; Gravino et al. 2005; Smit et al. 1998). Benzodiazepines, such as midazolam or lorazepam, are commonly used to produce anxiolysis and sedation before the procedure is started.

Currently, there are no specific guidelines for monitoring requirements during thoracoscopy. Thoracoscopy, especially when done under local anaesthesia, is a short procedure and does not warrant invasive intraoperative monitoring. An intravenous peripheral line should be inserted to administer fluids and medication during the procedure. Oxygen is given via nasal canula or face mask. Basic mandatory monitoring, when sedation and analgesia is administered, should include continuous electrocardiographic monitoring, digital pulse oximetry and regular non-invasive blood pressure measurements (at least every 5 min). General anaesthesia should be undertaken in the presence of trained personnel, and additional monitoring is required including capnography or capnometry, blood pressure monitoring and continuous or regular temperature measurements. The American Society of Anesthesiologists publishes a standard of care for basic intraoperative monitoring (Standards for basic anesthetic monitoring – http:​/​/​www.​asahq.​org/​publicationsAndS​ervices/​sgstoc.​htm).

Many authors have confirmed that thoracoscopy for the diagnosis of pleural disease can be performed safely under local anaesthesia (Oldenburg and Newhouse 1979; Gravino et al. 2005). The procedure can be performed using local anaesthesia with “conscious sedation” (Loddenkemper 1998; Boutin et al. 1991; Menzies and Charbonneau 1991). This widely used term, also known as diaz-analgesia, refers to a patient who remains awake or arousable and spontaneously breathing while having been administered small doses of anxiolytics and analgesics. This is distinguished from sedation, during which the patient is unconscious and spontaneously breathing and not intubated (Smit et al. 1998; Danby et al. 1998; Migliore et al. 2002). These techniques contrast to general anaesthesia, during which the airway is fully controlled by the insertion of an endotracheal tube or laryngeal mask.

The most commonly used drugs for sedation are midazolam and propofol. Benzodiazepines, such as midazolam or diazepam, are more widely used because they cause less hemodynamic instability and respiratory depression than propofol. Analgesia is given concurrently, most commonly in the form of short-acting synthetic opiates such as fentanyl, remifentanil or sufentanil. Sedatives and analgesics can be given either as continuous IV perfusions or as boluses. Only one small randomised trial compared the use of sufentanil given in boluses and continuous remifentanil during thoracoscopy and found no difference between the two techniques (Gravino et al. 2005). The choice of analgesic and sedative drugs should thus be based on local expertise and policy.

The simplest way to perform local anaesthesia is by local anaesthetic infiltration of the lateral thoracic wall and parietal pleura (Buchanan and Neville 2004; Horswell 1993; Boutin et al. 1991). Lidocaine or mepivacaine with epinephrine is infiltrated at the sites of proposed trocar insertion before the incision is made. Some authors have also used ropivacaine instead of lidocaine (Gravino et al. 2005; Migliore et al. 2002). In addition to the skin, the intercostal muscle, neurovascular bundle and underlying pleura of the chosen intercostal space should be extensively anaesthetised. The addition of epinephrine to the anaesthetic mixture reduces the amount of blood oozing on the pleural side of the port, making visualisation easier and, in addition, reducing blood contamination of the thoracoscope (Rodriguez-Panadero et al. 2006; Horswell 1993). Once a pneumothorax is established, local anaesthetic may be nebulised or sprayed with a catheter on the parietal pleura for further anaesthesia. This technique of spray catheter pleural anaesthesia has been shown to reduce pain prior to talc poudrage for spontaneous pneumothorax (Lee and Colt 2007b). Intercostal nerve blocks or thoracic epidural anaesthesia is other means of providing more complete analgesia but should be done by a trained physician (Horswell 1993).