Efficacy and Safety of Remimazolam versus Dexmedetomidine and Midazolam in Awake Endotracheal Intubation for Difficult Airway Patients: A Randomized Controlled Study.

Objective: To compare the safety and efficacy of remimazolam, dexmedetomidine, and midazolam in awake endotracheal intubation by flexible bronchoscopy for patients with difficult airways. Methods: Ninety patients with difficult airways undergoing elective surgical procedures requiring awake endotracheal intubation under general anesthesia were randomly assigned to three groups, with 30 patients per group: Group M (midazolam), which received a 0.04 mg/kg intravenous (IV) bolus; Group D (dexmedetomidine), which was given via intravenous infusion pump at a rate of 1.0 µg/kg/min for 10 minutes; and Group R (remimazolam), which received a 0.15 mg/kg IV bolus. All patients first received 0.1μg/kg of sufentanil intravenously for basic analgesia. A 2-minute interval was allowed to ensure initial onset of the analgesic effect, followed by administration of the respective sedative agents for each group as detailed above. Upon achieving a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of≤2, pharyngeal topical anesthesia was administered, followed by flexible fiberoptic endotracheal intubation. The primary outcome measure was the first-attempt intubation success rate. All other evaluated parameters were defined as secondary outcomes. Mean arterial pressure (MAP), heart rate (HR), and oxygen saturation (SpO Results: The first-attempt intubation success rates across the three groups were 70%, 93.3%, and 100%, respectively. Compared with the values at T Conclusion: Remimazolam provides effective sedation for awake tracheal intubation in patients with difficult airways. It exerts minimal impact on respiratory and circulatory function, is associated with fewer adverse events, and yields a higher intubation success rate, making it a favorable option for this patient population.