Remimazolam compared with propofol, dexmedetomidine, and midazolam for adult sedation in flexible bronchoscopy: a systematic review and meta-analysis

TL;DR

This study compares remimazolam to other sedatives for bronchoscopy, finding it safer and more effective in reducing breathing issues and recovery time.

Contribution

The study introduces remimazolam as a safer and more effective sedative alternative for flexible bronchoscopy compared to propofol, dexmedetomidine, and midazolam.

Findings

Remimazolam reduced respiratory depression, hypoxia, bradycardia, and hypotension compared to other sedatives.

It improved patient satisfaction and reduced recovery time when compared to dexmedetomidine.

Remimazolam shortened induction and recovery times and increased sedation success compared to midazolam.

Abstract

Remimazolam, a short-acting benzodiazepine, has emerged as a potential safer alternative for sedation in Flexible Bronchoscopy (FB). This meta-analysis compares its efficacy and safety with Propofol, Dexmedetomidine, and Midazolam in adult patients undergoing FB.

PubMed, Embase, and Cochrane databases were searched on July 17, 2025, for trials comparing Remimazolam with other sedatives. Primary outcomes included hypotension, bradycardia, and intraprocedural opioid consumption; secondary outcomes were hypoxia, respiratory depression, patient satisfaction, induction time, and recovery time. Pooled Risk Ratios (RR), Mean Differences (MD), and Standardized Mean Differences (SMD) were calculated using a random-effects model in R (4.4.0). Risk of bias was assessed using the RoB2 tool, and subgroup analyses were conducted for each comparator.

Eleven trials (1,884 patients) were included. Remimazolam reduced respiratory depression (RR = 0.44 [95% CI 0.29; 0.67]; p = 0.0002; I² = 0%), hypoxia incidence (RR = 0.60 [95% CI 0.39; 0.93]; p = 0.0227; I² = 64.7%), bradycardia (RR = 0.39 [95% CI 0.20; 0.77]; p = 0.0069; I² = 52.3%), and hypotension (RR = 0.61 [95% CI 0.40; 0.95]; p = 0.0289; I² = 74.0%) compared to all sedatives. Compared to Propofol, Remimazolam reduced the incidence of hypotension (RR = 0.42 [95% CI 0.31; 0.58]; p < 0.0001; I² = 0%), respiratory depression (RR = 0.41 [95% CI 0.25; 0.68]; p = 0.0005; I² = 12.3%), but increased induction time (MD = 0.61 min [95% CI 0.23; 0.99]; p = 0.002; I² = 90.9%). Compared to Dexmedetomidine, it improved satisfaction (SMD = 0.23 [95% CI 0.07; 0.39]; p = 0.004; I² = 0%) and reduced recovery time (MD = -1.79 min [95% CI -2.66; -0.92]; p < 0.001; I² = 90.7%), hypoxia incidence (RR = 0.49 [95% CI 0.28; 0.88]; p = 0.0162; I² = 60.3%), and induction time (MD = -2.21 min [95% CI -2.41; -2.00]; p < 0.001; I² = 0%). Compared to Midazolam, Remimazolam increased sedation success (RR = 2.03 [95% CI 1.40; 2.95]; p = 0.0002; I² = 50%), shortened induction time (MD = -0.69 min [95% CI -1.37; -0.01]; p = 0.047; I² = 81.5%), and recovery time (MD = -4.49 min [95% CI -7.06; -1.92]; p < 0.001; I² = 40.9%).

Remimazolam reduced respiratory depression overall and demonstrated improved safety, faster recovery, and greater efficacy compared to Propofol, Dexmedetomidine, and Midazolam, respectively, supporting its potential as an effective alternative for sedation in FB. Nonetheless, substantial heterogeneity in certain outcomes and the relatively small sample size in some comparisons limit the generalizability of our findings.

PROSPERO (CRD 42024568148).

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