Comparative efficacy and safety of remimazolam versus propofol in bronchoscopic procedures: a GRADE-assessed systematic review and meta-analysis

Bronchoscopy is a widely performed diagnostic and therapeutic intervention in pulmonary medicine. Sedatives are recommended with it to improve patient comfort and procedural outcomes. Propofol, the traditional sedative, carries risks of hemodynamic and respiratory adverse events, particularly in elderly or comorbid patients. Remimazolam, an ultra-short-acting benzodiazepine, is being explored as a potential alternative with a better safety profile. To systematically evaluate the efficacy and safety of remimazolam versus propofol for bronchoscopic procedures. Systematic review and meta-analysis of randomized controlled trials (RCTs). PubMed, Embase, Scopus, Web of Science, Cochrane, ClinicalTrials.gov and WHO ICTRP were searched upto May 23, 2025 for RCTs comparing remimazolam to propofol in bronchoscopy. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool, and random-effects models were used to pool outcomes in R software. Certainty of evidence was assessed using the GRADE approach. Six RCTs met the eligibility criteria and were included, involving 718 patients (359 in each group, mean ages 49.7 to 71.5 years, ASA status I-IV). No significant differences were observed in time to loss of consciousness, time to awake, or successful sedations. However, remimazolam use was associated with a significantly lower risks of hypotension (Risk Ratio RR 0.46, 95% Confidence Interval CI 0.30–0.71, moderate certainty), hypoxemia (RR 0.38, 95% CI 0.29–0.50, moderate certainty) and injection pain (RR 0.05, 95% CI 0.01–0.19, moderate certainty). Remimazolam provides comparable sedation efficacy during bronchoscopy to propofol, but with a better safety profile, showing lower risks of hypotension, hypoxemia, and injection pain. High-quality, adequately powered studies are needed, however, to confirm these findings and guide sedation strategies for specific patient needs.