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Thank you for your thorough and thoughtful revision. I have carefully reviewed your rebuttal and the updated manuscript. You have satisfactorily addressed the editor’s and reviewers’ comments, including expansion of the discussion and limitations, clarification of your study’s novel contribution and clinical implications, and improvement of figures and reporting details.
On this basis, and given the positive reviewer recommendation, I am pleased to confirm that your manuscript is accepted for publication.
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Thank you for submitting your manuscript. After careful consideration of the reviews and my own assessment, I am inviting you to submit a revised version.
While your study is well structured and of clinical relevance, several important issues must be addressed before further consideration:
1) Discussion and limitations: Expand your discussion to include other factors influencing outcomes (e.g., depth of sedation, clinical variables).
2) Explicitly state the limitations of your work, including heterogeneity in the propofol studies, restricted evidence base, and secondary nature of the analysis.
3) Novel contribution and clinical relevance: Clarify what new knowledge your study adds beyond existing reviews.
4) Provide more practical guidance for readers on how your findings might be applied in clinical practice.
5) Figures and clarity: x-axis units in Figure 1, Improve figure resolution, particularly the forest plots, to ensure readability.
6) Specific reviewer queries: Address the points raised about opioid requirements, subgroup effects (e.g., dexmedetomidine variability), and airway management if data permit.
These revisions will substantially strengthen the manuscript by improving clarity, interpretability, and clinical relevance.
We look forward to receiving your revised submission.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and that any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
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The study is interesting. I have no observations except that I would prefer to use R rather than Revman for the analysis.
Line 236: "AIncidence of adverse events", please correct if it is right?
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This manuscript is clearly written and well organized. The authors follow PRISMA guidelines and the Cochrane Handbook, with transparent data sources and clearly defined inclusion and exclusion criteria. The reasoning is consistent, and the results correspond to the research questions.
However, there are some figures lack clarity, especially the forest plots (Fig.4 or 3?), where details are difficult to see. Higher-resolution images are recommended to make the results easier for readers to interpret.
This work is a systematic review and meta-analysis limited to randomized controlled trials (RCTs), I think it fits the scope of the journal and has clinical value. The research question is clearly stated and addresses an important issue in sedation practice for bronchoscopy.
Although this work is a secondary data analysis, the authors set clear rules for which studies to include and used the Cochrane RoB 2 tool to check for bias, which makes the methods more reliable.
The review incorporates 13 RCTs with a total of 2,002 participants, providing a robust sample size. Data were combined with a random-effects model, which takes into account the differences between studies. The conclusions are generally consistent with the data and are not overstated. Importantly, the authors explicitly acknowledge that the findings regarding propofol are inconclusive due to substantial heterogeneity, reflecting a cautious interpretation of the evidence.
For revision, it would be helpful if the authors could further elaborate on: 1. Why clinical studies comparing remimazolam and propofol are relatively limited. 2. What factors contribute to the inconsistency in dosing, modes of administration, and definitions of recovery time. Clarifying these issues would help readers better understand the clinical context behind the inconclusive results for propofol.
Overall, the data in this work are clear and openly reported. The methods are reliable, and the authors note the limits of using secondary data. The findings give useful information for clinical practice. Apart from making the figures clearer and giving more explanation about the propofol comparison, the manuscript is ready for publication.
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1. This is a meta-analysis.
1. Several factors associate with the outcome of the study. Please discuss these.
2. Intravenous sedation was utilized for bronchoscopy in this study. Generally, the physicians know that the different depth of sedation level could produce the different outcome. How about the depth of sedation during the procedure?
The article is aimed to evaluate the comparative efficacy and safety of remimazolam versus established sedatives (dexmedetomidine, propofol, midazolam) for sedation during bronchoscopy. The title is “Comparison of the safety and efficacy of remimazolam for sedation during bronchoscopy: a meta-analysis of randomized controlled trials”.
1. Please add the limitations of the study in the discussion section.
2. What is the new knowledge of the study?
3. Please also recommend the readers “How to apply this knowledge in clinical practice?”.
Line 236: Is that title supposed to be Incidence of adverse events? It currently looks like “AIncidence of adverse events.”
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Really nice paper. Excellent review of a popular, emerging medication with a wide variety of potential applications highlighting a challenging anesthetic that can be made potentially safer with its use. Well done. I just have a couple questions moreso than actual necessary changes to the paper. Well done using the data available and establishing quality and appropriate conclusions from the data available.
Figure 1: Any comments from Figure 1 on the amount of opioids required with remimazolam compared to other sedatives and if there’s statistical significance between the medications with regard to their opioid demand in addition to the sedative hypnotic agent being studied?
Line 265-267: Excellent point about the pharmacodynamic variability in dexmedetomidine impacting clinical dosing strategies. Is it possible to expand on which and how specific patient subgroups modulate the effect of the comparison between dexmedetomidine and remimazolam?
General Question: Were there any data regarding comparative difficulty in airway placement if routinely used: i.e. supraglottic airway vs. endotracheal tube vs. bronchoscopy with natural airway?
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