Sedation during dynamic bronchoscopy for expiratory central airway collapse: Which is the ideal protocol?

Objective

To compare sedation protocols for dynamic bronchoscopy (DB) in the evaluation of expiratory central airway collapse (ECAC).

Materials and methods

This observational study included adult patients (≥18 years) referred to Mayo Clinic, Jacksonville, FL, from March 2023 to July 2024, for suspected ECAC. Patients were grouped based on sedation protocols: propofol (Protocol 1), remimazolam (Protocol 2), and remimazolam/fentanyl (Protocol 3). The primary outcome was the quality of assessment during DB, rated on a 4-point Likert scale (1 = poor, 4 = excellent). Secondary outcomes included anesthesia duration and post-anesthesia care unit (PACU) length of stay. Statistical analyses included Fisher's exact test, ordinal logistic regression, and Kruskal-Wallis tests.

Results

Seventy-three patients met the inclusion criteria. Overall, DB quality of assessment was significantly associated with sedation protocol (P=0.01 Ordinal regression results suggest that protocol 3 (remimazolam/fentanyl) may be comparable to protocol 1 (propofol) (OR0.40, 95%CI 0.12–1.33, P = 0.13), with both showing a tendency for better performance than protocol 2 (remimazolam) (OR0.14, 95%CI 0.04–0.46 P=0.002 vs protocol 3; OR0.35, 95%CI 0.09–0.29 P=0.115 vs protocol 1). No significant differences were found in PACU length of stay among the three protocols (P = 0.13). No post-procedural complications were reported.

Conclusion

Protocol 3 (remimazolam/fentanyl) demonstrated significantly higher odds of achieving a better quality of assessment compared to Protocol 2 (remimazolam) and showed comparable performance to Protocol 1 (propofol). These findings suggest that remimazolam/fentanyl is an effective sedation option for DB, providing improved assessment quality without increasing PACU stay. Larger prospective studies are necessary to confirm these results.