Remifentanil versus dexmedetomidine in awake fiberoptic bronchoscopy guided laryngeal surgeries

Background: Awake fiberoptic bronchoscopy (AFB) is an essential technique for securing the airway in patients with complex anatomical challenges, such as laryngeal masses, where conventional intubation may be difficult. This study compares the efficacy of remifentanil and dexmedetomidine for sedation during AFB in patients undergoing laryngeal surgery. Methods: This retrospective cohort study analyzed the data of 76 patients who underwent AFB for tracheal intubation between January 2021 and April 2024. The patients were divided into two sedation groups: Remifentanil (n = 38) and Dexmedetomidine (n = 38). The primary outcomes included intubation time, the number of intubation attempts, patient comfort scores, and postoperative cough scores. Sedation was titrated to achieve a Ramsay sedation score of 3–4, and to ensure comparability, baseline characteristics such as demographic data, American Society of Anesthesiologists (ASA) classifications and Mallampati scores were compared. Results: The baseline characteristics were similar between the two groups. However, dexmedetomidine was associated with significantly shorter intubation times (52.39 ± 16.94 vs. 70.50 ± 20.42 seconds, p < 0.01), fewer intubation attempts (1.58 ± 0.56 vs. 2.08 ± 0.62, p < 0.01) and better patient comfort scores (1.82 ± 0.56 vs. 2.13 ± 0.62, p = 0.02). Additionally, postoperative cough scores were lower in the dexmedetomidine group (2.00 ± 0.61 vs. 2.32 ± 0.57, p = 0.02), indicating reduced airway irritation after the procedure. Conclusions: Dexmedetomidine was associated with superior sedation compared to remifentanil for AFB in patients undergoing laryngeal surgery due to improved patient comfort, shortened intubation time and reduced number of intubation attempts. The lower postoperative cough scores further suggest a potential benefit in minimizing airway irritation. Given its minimal respiratory depressive effects and enhanced procedural efficiency, dexmedetomidine could be the preferred sedative agent for AFB in this patient population.

Awake fiberoptic bronchoscopy; Sedation; Remifentanil; Dexmedetomidine; Laryngeal surgery

[1] Hyman JB, Rosenblatt WH. Awake intubation techniques, and why it is still an important skill to master. Current Anesthesiology Reports. 2022; 12: 382–389.

[2] Merola R, Vargas M, Marra A, Buonanno P, Coviello A, Servillo G, et al. Videolaryngoscopy versus fiberoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis of randomized controlled trials. Journal of Clinical Medicine. 2024; 13: 3186.

[3] Wilhelm W, Kreuer S. The place for short-acting opioids: special emphasis on remifentanil. Critical Care. 2008; 12: S5.

[4] Deasy A, Doody K. Dexmedetomidine—a superior sedative agent for patients undergoing awake fibreoptic intubation. Irish Medical Journal. 2023; 116: 755.

[5] Zhou L, Huang Y, Zhou R, Liu S. Comparison of remimazolam and dexmedetomidine for sedation in awake endotracheal intubation in scoliosis surgery: a retrospective analysis. Medical Science Monitor. 2024; 30: e944632.

[6] Kollmeier BR, Boyette LC, Beecham GB, Desai NM, Khetarpal S. Difficult airway. StatPearls: Treasure Island (FL). 2023.

[7] Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update. British Journal of Anaesthesia. 2022; 129: 612–623.

[8] El-Boghdadly K, Desai N, Jones JB, Elghazali S, Ahmad I, Sneyd JR. Sedation for awake tracheal intubation: a systematic review and network meta-analysis. Anaesthesia. 2025; 80: 74–84.

[9] Cattano D, Lam NC, Ferrario L, Seitan C, Vahdat K, Wilcox DW, et al. Dexmedetomidine versus remifentanil for sedation during awake fiberoptic intubation. Anesthesiology Research and Practice. 2012; 2012: 753107.

[10] Sancheti AG, Swami SS, Konnur SL, Amin N. A comparative study between local dexmedetomidine and intravenous dexmedetomidine during awake fiberoptic nasotracheal intubation. Anesthesia, Essays and Researches. 2022; 16: 407–411.

[11] Hu R, Liu JX, Jiang H. Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial. Journal of Anesthesia. 2013; 27: 211–217.

[12] Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998; 88: 1467–1474.

[13] Rao S, Rai S, Das PK, Kumar S, Malviya D, Tripathi M. Effect of use of high-flow nasal cannula during fiberoptic intubation under general anesthesia: a randomized controlled trial. Anesthesia, Essays and Researches. 2020; 14: 632–637.

[14] Chen Q, Qin B, Zhang M, Zhou Y, Shi X, Xie Y. The safety and efficacy of remimazolam compared to dexmedetomidine for awake tracheal intubation by flexible bronchoscopy: a randomized, double-blind, controlled trial. Drug Design, Development and Therapy. 2024; 18: 967–978.

[15] Arora S, Govardhane BT, Srinivasan V, Karandikar G. Evaluation of different doses of dexmedetomidine for awake fibreoptic nasotracheal intubation in patients undergoing oromaxillofacial and oral malignancy surgeries: a randomised, double-blind study. Indian Journal of Anaesthesia. 2024; 68: 447–53.

[16] Rao PN, Soffin EM, Beckman JD. Comparative review of airway anesthesia and sedation methods for awake intubation. Current Opinion in Anesthesiology. 2023; 36: 547–559.

[17] Tang ZH, Chen Q, Wang X, Su N, Xia Z, Wang Y, et al. A systematic review and meta-analysis of the safety and efficacy of remifentanil and dexmedetomidine for awake fiberoptic endoscope intubation. Medicine. 2021; 100: e25324.

[18] Acharya R, Sriramka B, Koushik P. Comparison of dexmedetomidine alone with dexmedetomidine and fentanyl during awake fiberoptic intubation in patients with difficult airway: a randomized clinical trial. Journal of Dental Anesthesia and Pain Medicine. 2022; 22: 349–356.

[19] Sachan M, Singh NK, Naithani B, Abbas H, Dube M, Naithani B. Comparative study of intubating conditions and hemodynamic changes during awake fiber-optic intubation using midazolam with fentanyl versus dexmedetomidine in cases of difficult airway. National Journal of Maxillofacial Surgery. 2022; 13: 201–207.