Sedation for fiberoptic intubation of a spontaneously breathing patient remains challenging. Currently used sedatives such as propofol, midazolam, or opioids have their limitation. Remimazolam, a recently introduced ultra-short-acting benzodiazepine, has several desirable pharmacologic characteristics, including easily titratable levels of sedation, anxiolysis, minimal respiratory depression, and hemodynamic stability. Moreover, this drug has a unique pharmacokinetic profile that allows for a rapid transition between deep sedation and awake states. We report a successful asleep fiberoptic intubation in a patient with a difficult airway (Mallampati 4) sedated by remimazolam. The patient was spontaneously breathing throughout the procedure despite being deeply sedated. Conditions for intubation were excellent.
