Remimazolam compared with propofol, dexmedetomidine, and midazolam for adult sedation in flexible bronchoscopy: a systematic review and meta-analysis
Year: 2026
Type: review
Study designs: Systematic Review, Meta-Analysis
Abstract: BACKGROUND: 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. METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD 42024568148).
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7125580936