Preserving Airway Reflexes During Awake Intubation: A Cautionary Note on Deep Sedation Protocols [Letter]

We read with great interest the randomized controlled trial by Tang et al entitled "Efficacy and Safety of Remimazolam versus Dexmedetomidine and Midazolam in Awake Endotracheal Intubation for Difficult Airway Patients". 1 This study addresses a clinically important and evolving topic, about optimization of sedation strategies for awake tracheal intubation (ATI).The comparison of remimazolam (an agent not yet extensively studied in this context) with commonly used sedatives such as dexmedetomidine and midazolam represents a valuable and timely contribution to the literature.The authors should be commended for several strengths.First, conducting a prospective randomized study in a difficult airway population is inherently challenging, and the inclusion of 90 patients undergoing ATI is noteworthy. 2,3Second, the manuscript clearly outlines the desirable characteristics of an ideal sedative agent in this setting with rapid onset, maintenance of spontaneous ventilation, hemodynamic stability, and rapid recovery.Which provides a solid conceptual framework.Nevertheless, we would like to raise several points for consideration that may help contextualize the findings and guide future research.A central concern relates to the sedation strategy employed.The study targeted a MOAA/S score 2, which corresponds to deep sedation.However, current airway management principles emphasize minimal to moderate sedation during ATI in order to preserve airway reflexes and spontaneous ventilation. 4In fact, the authors themselves define the ideal sedation depth as MOAA/S 2-3, yet the protocol required progression to deeper levels, even including disappearance of the corneal reflex.This approach may not reflect routine clinical practice and could introduce safety concerns, particularly in a population already at risk of difficult ventilation.Moreover, some patients undergoing ATI may not require sedation at all, highlighting the importance of individualized, minimal sedation strategies.Related to this, the use of fixed initial doses followed by titration until a deep sedation threshold is reached may introduce bias when comparing agents with inherently different pharmacokinetics and administration routes.In the present study, midazolam and remimazolam were administered as boluses, whereas dexmedetomidine was given as an infusion.Comparing the time required to reach a predefined sedation level under these conditions may therefore be influenced more by the administration strategy than by intrinsic drug properties.Indeed, small modifications in dosing (eg., a lower midazolam dose) could plausibly alter the observed differences, raising questions about the robustness and reproducibility of the findings.The choice of primary outcome as first-attempt intubation success rate also deserves further reflection.While clinically meaningful, this outcome is multifactorial and depends not only on sedation but also on operator experience, airway anatomy, and adequacy of topical anesthesia.In this study, all intubations were performed by a highly experienced anesthesiologist, which likely contributed to the very high success rates, particularly in the remimazolam group.This