Remimazolam vs. propofol sedation for video laryngoscopy in cervical spondylosis patients with suspected difficult laryngoscopy: a randomized controlled trial

Abstract Background This study aimed to explore the efficacy and safety of remimazolam vs. propofol for sedation during video laryngoscopy in cervical spondylosis patients with suspected difficult laryngoscopy. Methods In this single-center, prospective, randomized controlled study, 85 patients with Modified Mallampati class III or IV and limited cervical spine mobility were recruited and randomly assigned (1:1 ratio) to receive either remimazolam or propofol sedation. The primary outcome was the incidence of hypoxemia (SpO₂< 90% for >10 s). Secondary outcomes included sedation efficacy and side effects. Results The incidence of hypoxemia was significantly lower in the remimazolam group (13.6%) than in the propofol group (39.0%; P = 0.008), with an absolute risk difference of 25.4% (95% confidence interval 0.073–0.434). The propofol group required more additional airway interventions ( P = 0.007). After adjusting for age, gender, and body mass index, propofol was associated with higher odds of hypoxemia (adjusted odds ratio = 4.602; 95% confidence interval 1.330–15.922; P = 0.016) and more advanced airway interventions (adjusted odds ratio = 4.598; 95% confidence interval 1.395–15.152; P = 0.012). Injection pain occurred in 31.7% of propofol patients but was absent in the remimazolam group ( P < 0.001). Conclusions Remimazolam provides effective and safe sedation for video laryngoscopy in cervical spondylosis patients with suspected difficult laryngoscopy, significantly reducing the incidence of hypoxemia and the need for airway interventions compared to propofol. Trial registration: This protocol was approved by Peking University Third Hospital Medical Science Research Ethics Committee (IRB00006761–M2024420, June 2024) and was prospectively registered with the Chinese Clinical Trial Registry (ChiCTR2400086137, June 2024).