Comparison of older and newer sedation agents in bronchoscopy

Table 1 Pharmacokinetics, advantages and disadvantages of sedatives used in bronchoscopy

Medication	Pharmacokinetics	Metabolic pathway	Advantages	Disadvantages	Adverse effects
Midazolam	Onset: 30–60 seconds; duration: 2 hours	Primarily hepatic	Reversal agent (Flumazenil), amnesia, cerebral protection	Risk of liver disease	Respiratory depression, hypotension, nausea, pain/swelling at injection
Diazepam	Onset: 1–5 minutes; duration: 6–8 hours; half-life: Approximately 100 hours	Hepatic	Long-acting, Flumazenil antidote, large therapeutic window	Less potent, long-duration	Sedation, dizziness, hypotension, respiratory depression, dependency
Propofol	Onset: 30 seconds; duration: 3–10 minutes	Hepatic	Fast onset, anti-emetic, bronchodilator, less cough	Poor amnesia, complex recovery	Hypotension, respiratory depression, bradycardia, pain, infection risk, high mortality risk in pediatric population
Fentanyl	Onset: 1–2 minutes; duration: 30–60 minutes	Hepatic CYP3A4	Strong analgesic, rapid onset	High respiratory depression, bradycardia	Nausea, vomiting
Ketamine	Onset: 10–30 seconds; duration: 5–15 minutes	Hepatic	Dissociative, bronchodilator, airway reflex preserved	Hallucinations, long recovery	Elevated blood pressure, hallucinations, worsens psychosis
Ketofol	Onset: 30 seconds; duration: 5-10 minutes1	Hepatic	Synergistic sedation, combines benefits	No standard ratio, and there remains risk of apnea	Hallucinations, nausea, secretions, respiratory depression
Remifentanil (Ultiva)	Onset: 1–2 minutes; duration: 5–10 minutes	Tissue esterases and blood	Very fast onset/offset, ideal for short procedures	Expensive, needs close monitoring	Respiratory depression, bradycardia, hypotension, nausea
Dexmedetomidine	Onset: 10–15 minutes; duration: 1–2 hours	Hepatic	No respiratory depression, less nausea/vomiting/delirium	Long onset, Prolonged recovery, liver clearance impacted	Hypotension bradycardia
Esketamine (Spravato)	Onset: 5–10 minutes; duration: 20–40 minutes; half-life: 7–12 hours2	Hepatic	Fast, stable hemodynamics, fast recovery, less desaturation	Expensive, limited data	Dissociation, elevated BP, nausea, dizziness3, psychiatric/visual symptoms3

¹Duration varies depending on Ketamine-Propofol ratio.

²Based on intramuscular nasal formulation due to lack of clinical studies.

³Specifically in the pediatric population based on studies.

Table 2 Year of introduction and pricing of sedatives used for bronchoscopy

Medication	First use in bronchoscopy	Price (approx)1
Midazolam	1980s	1 mg/mL: $14.58 5 mg/mL: $14.56
Diazepam	1960s	2 mL: $8.29–$14.60/mL (10 vial minutes) 10 mL: $3.84–$4.72/mL (10 vial minutes)
Propofol	1980s	20 mL: $5, 50 mL: $10, 100 mL: $20
Fentanyl	1968	2 mL: $1.49/vial, 20 mL: $13.89/vial
Ketamine	1970s	20 mL: $18, 10 mL: $6, 5 mL: $10
Ketofol	2000s	Based on Ketamine and Propofol concentrations used
Remifentanil (Ultiva)	1996	1 mg: $36.21–$62.5, 12 mg: $103.83–$141.57, 5 mg: $219.33–$286.49
Dexmedetomidine	1999 (FDA-approved)	$45.21 per 2 mL vial (100 μg/mL)
Esketamine (Spravato)	2010s (FDA: 2019)	56 mg dose: $440.08; 84 mg dose: $438.54

¹Prices fluctuate with overall marketing supply and demand, supply chain considerations, and hospitals’ overall storage, handling, and administration costs.

FDA: Food and Drug Administration.