PURPOSE: This study evaluated the efficacy of adding budesonide to nebulized lidocaine in patients undergoing flexible bronchoscopy (FB) under topical anaesthesia. STUDY DESIGN: Patients aged ≥18 years, scheduled for FB under topical anaesthesia were randomized into two groups: the combination group received a pre-treatment of 2 ml 1 mg budesonide with 5 ml 2% lidocaine, whilst the lidocaine group received 5 ml 2% lidocaine with 2 ml saline solution, both administered via nebulization. Blood pressure (BP), heart rate, and percutaneous oxygen saturation were recorded before, during, and 10 min after FB. The Visual Analogue Scale (VAS) and Wong-Baker FACES Pain Rating Scale (FPS-R) were used to evaluate cough severity, discomfort, willingness to accept reoperation, and the operator's satisfaction with patient cooperation. In addition, the duration of the procedure, total lidocaine dosage instilled through the bronchoscope during the procedure, and types of procedures performed were documented. RESULTS: Compared to the lidocaine group, the combination group showed lower maximum systolic and diastolic BP, higher minimum percutaneous oxygen saturation, and lower cough and discomfort severity scores. Operator's satisfaction, as measured via the VAS or FPS-R, was greater in the combination group, which also exhibited shorter procedure times and required lower lidocaine dosages. There were no significant differences between the groups in terms of willingness to accept reoperation or types of procedures performed. CONCLUSIONS: In patients undergoing FB with topical anaesthesia, pre-treatment with a combination of nebulized lidocaine and budesonide is more effective than nebulized lidocaine alone. Key message What is already known on this topic? Flexible bronchoscopy (FB) with topical anaesthesia remains a common practice in many settings, although it can cause significant discomfort for patients. What this study adds? Pre-treatment with a combination of nebulized budesonide and lidocaine was more effective and safer than nebulized lidocaine alone for improving patient tolerance during FB. How this study might affect research, practice, or policy? In settings where conscious sedation is not feasible, the combined nebulization of lidocaine and budesonide may offer an optimized approach for FB, enhancing patient comfort and procedural efficiency.