- Design
- Systematic review and meta-analysis of randomised controlled trials
- Population
- 16 trials, 2,325 adults having fibreoptic bronchoscopy
- Primary outcome
- Respiratory depression, hypotension, bradycardia, success and recovery
- Effect
- Respiratory depression RR 0.51 (0.36 to 0.73); hypotension RR 0.50 (0.34 to 0.73)
This meta-analysis pooled 16 randomised trials and 2,325 adults having fibreoptic bronchoscopy under sedation with remimazolam, an ultra-short-acting benzodiazepine, against dexmedetomidine, midazolam or propofol.
Remimazolam was associated with less respiratory depression (RR 0.51, 95% CI 0.36 to 0.73), less hypotension (RR 0.50, 0.34 to 0.73) and less bradycardia (RR 0.37, 0.22 to 0.65). Procedural success was similar (RR 1.12, 0.98 to 1.28). Onset was about two minutes faster than dexmedetomidine but about half a minute slower than propofol. Emergence and recovery unit stay were shorter than with dexmedetomidine or midazolam.
Bronchoscopy shares the airway between operator and sedationist, so a drug that keeps patients breathing and normotensive matters more here than in most procedures. The safety estimates pool three different comparator drugs, so the size of the advantage over propofol specifically is less certain. Where remimazolam is available and affordable, it is a reasonable first choice for patients with limited respiratory or cardiovascular reserve.
- Consider remimazolam for bronchoscopy sedation in patients with limited respiratory or cardiovascular reserve.
- Expect onset slightly slower than propofol and faster than dexmedetomidine.
- Keep continuous oxygen saturation and capnography monitoring whatever sedative is used.
- Have flumazenil available, since remimazolam is a benzodiazepine.
- Check local availability and cost before changing a sedation protocol.
Why it matters
Sedation for bronchoscopy is limited by the airway, and this drug appears to protect it better than the usual options.
Don't overread it
The comparators were pooled, so the advantage over propofol alone may be smaller than the headline suggests.
The statistics, in plain English
A risk ratio of 0.51 for respiratory depression means about half as many episodes as with the comparators, and the interval stays well below 1.0. Success was similar: the interval for success, 0.98 to 1.28, crosses 1.0, so no difference was shown.
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