A systematic review and meta-analysis of the safety and efficacy of remifentanil and dexmedetomidine for awake fiberoptic endoscope intubation

Abstract

Background: Awake fiberoptic endoscope intubation (AFOI) is the primary strategy for managing anticipated difficult airways. Adequate sedation, most commonly being achieved with remifentanil and dexmedetomidine, is integral to this procedure. This meta-analysis aimed to compare the safety and efficacy of these 2 sedatives.

Methods: We conducted electronic searches in Embase, Web of Science, PubMed, Google Scholar, Medline, Springer, and Web of Science with no language restrictions. Studies comparing safety and efficacy between the sole use of remifentanil and dexmedetomidine among patients who underwent AFOI were included. Eight randomized controlled trials, comprising 412 patients, met the inclusion criteria. The primary outcomes were first attempt intubation success rate and incidence of hypoxia. The secondary outcomes were the Ramsay Sedation Scale score at intubation, memory recall of endoscopy, and unstable hemodynamic parameters during intubation.

Results: Dexmedetomidine significantly reduced the incidence of hypoxemia during AFOI (risk ratio: 2.47; 95% confidence [CI]: 1.32-4.64]) compared with remifentanil; however, the first intubation success rates were equivalent (risk ratio: 1.12; 95% CI: 0.87-1.46]. No significant differences between the 2 sedatives were found for the Ramsay Sedation Scale score at intubation (mean difference: -0.14; 95% CI: -0.66-0.38) or unstable hemodynamic parameters during intubation (risk ratio: 0.83; 95% CI: 0.59-1.17). Dexmedetomidine reduced memory recall of endoscopy (risk ratio: 1.39; 95% CI: 1.13-1.72).

Conclusions: While both remifentanil and dexmedetomidine are effective for AFOI and well-tolerated, dexmedetomidine may be more effective in reducing the incidence of hypoxemia and memory recall of endoscopy.

Prosperp registration number: CRD42020169612.

Figure 1

PRISMA flow diagram. PRSIMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Evaluation of risk of bias for each included study. Green circle indicates low risk of bias, red circle indicates high risk of bias, yellow circle indicates unclear risk of bias.

Figure 3

Forest plot of the meta-analysis: success rate of intubation at the first attempt between 2 agents.

Figure 4

Forest plot of the meta-analysis: incidence of hypoxia during intubation between 2 agents.

Figure 5

Forest plot of the meta-analysis: level of sedation during intubation between 2 agents.

Figure 6

Forest plot of the meta-analysis: unstable hemodynamic parameters during procedures between 2 agents.

Figure 7

Forest plot of the meta-analysis: postsurgical recall of endoscopy procedure between 2 agents.