Laryngoscopy and tracheal intubation are among the most frequently performed procedures in general anesthesia, yet they are recognized as potent noxious stimuli that provoke significant cardiovascular responses. These transient hemodynamic changes—characterized by elevations in heart rate and blood pressure—are primarily driven by a surge in sympathetic nervous system activity. Although often short-lived, this stress response can have serious consequences, particularly in patients with compromised cardiovascular, neurologic, or pulmonary reserves. Complications such as myocardial ischemia, arrhythmias, stroke, pulmonary edema, and elevated intracranial pressure have all been associated with exaggerated pressor responses to airway manipulation.1,2

To mitigate this sympathetic activation, anesthesiologists have historically employed various pharmacological strategies, including opioids, beta-blockers, calcium channel blockers, vasodilators, intravenous lignocaine, and volatile anesthetics. More recently, α2-adrenoceptor agonists like dexmedetomidine have gained prominence due to their unique pharmacodynamic profile—combining sedation, anxiolysis, analgesia, and sympatholytic effects without causing significant respiratory depression. However, when administered intravenously, dexmedetomidine carries the risk of bradycardia and hypotension, which has led to growing interest in alternative delivery routes such as nebulization. Nebulized dexmedetomidine offers favorable mucosal bioavailability (approximately 65% via nasal and 82% via buccal routes) and may attenuate hemodynamic responses with fewer systemic side effects compared to intranasal or intravenous administration.3-5

In parallel, the use of local anesthetics to blunt the stress response to intubation has also been explored. Ropivacaine, an amide-type long-acting local anesthetic, is structurally related to bupivacaine but with a more favorable safety profile. Being a pure S(-) enantiomer, it was developed to minimize cardiotoxicity while preserving sensory over motor blockade—making it potentially valuable for perioperative applications. When administered via nebulization, ropivacaine may offer a non-invasive, easily titratable method to anesthetize the airway and suppress the afferent nociceptive input responsible for triggering sympathetic excitation during laryngoscopy.6-8

Despite the individual promise of both agents, comparative studies assessing the efficacy and safety of nebulized dexmedetomidine versus nebulized ropivacaine in attenuating intubation-induced cardiovascular stress remain limited. Therefore, this prospective randomized study was undertaken to evaluate and compare the hemodynamic effects of nebulized dexmedetomidine and ropivacaine in patients undergoing elective surgeries under general anesthesia. The aim was to provide evidence that could inform best practices in airway management, particularly in high-risk populations, by identifying the more effective agent in blunting the cardiovascular response to laryngoscopy and intubation.

Study Design and Setting

This was a prospective, randomized, comparative clinical study conducted over a period of 18 months in the Department of Anesthesiology at Rajshree Medical Research Institute, Bareilly, India. The study was approved by the Institutional Ethics Committee, and written informed consent was obtained from all participants prior to enrollment.

Study Population

Patients aged 20–60 years, of either gender, scheduled for elective surgical procedures under general anesthesia with endotracheal intubation were considered for inclusion. Eligible participants were classified as American Society of Anesthesiologists (ASA) physical status Grade I or II, with a Mallampati score of I or II.

Inclusion Criteria

• Age between 20 and 60 years
• ASA physical status I or II
• Mallampati classification I or II
• Elective surgeries requiring general anesthesia with endotracheal intubation
• Provision of written informed consent

Exclusion Criteria

• Refusal to provide informed consent
• Mallampati score III or IV
• ASA grade III or above
• Anticipated or known difficult airway
• Emergency surgical cases

Randomization and Group Allocation

Participants were randomly assigned into two groups using a computer-generated randomization table:

• Group D: Received nebulized dexmedetomidine
• Group R: Received nebulized ropivacaine

Group allocation was concealed in opaque, sealed envelopes and revealed just prior to drug administration.

Study Drugs and Equipment

• Drugs Used:
  • Premedication and induction: Glycopyrrolate, Fentanyl, Midazolam, Ondansetron, Propofol, Vecuronium, Isoflurane, Neostigmine
  • Study drugs: Dexmedetomidine (nebulized), Ropivacaine (nebulized)
• Airway Equipment:
  • Endotracheal tubes (sizes 7.0 and 7.5 mm internal diameter)
  • Macintosh laryngoscope blades (size 3 and 4)
• Monitoring Devices:
  • Non-invasive blood pressure (NIBP) monitor
  • Electrocardiogram (ECG)
  • Pulse oximeter (SpO₂)
  • Capnograph

Intervention Protocol

All patients were premedicated according to institutional protocol. The study drug was administered via nebulization 15 minutes prior to anesthesia induction.

• Group D received dexmedetomidine
• Group R received ropivacaine

Standard anesthesia induction was performed using intravenous propofol and vecuronium for neuromuscular blockade. Intubation was carried out by an experienced anesthesiologist using a Macintosh laryngoscope. Anesthesia was maintained using isoflurane in oxygen and air mixture.

Data Collection and Monitoring

Hemodynamic parameters—heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP)—were recorded at the following time points:

• Baseline (pre-drug administration)
• Post-nebulization
• Post-induction
• 1, 3, 5, 10, 15, and 20 minutes after intubation

Additional parameters recorded included:

• Time to extubation
• Time to response
• Time to full recovery
• Ramsay sedation scores at defined postoperative intervals
• Visual Analog Scale (VAS) pain scores
• Incidence of adverse effects (e.g., bradycardia, hypotension, nausea, vomiting, shivering)
• Postoperative oxygen requirement
• Intraoperative anesthetic consumption (propofol, vecuronium, isoflurane)
• Intraoperative blood loss
• Patient satisfaction scores

Statistical Analysis

Data were compiled using a predesigned case record form. Statistical analysis was performed using [insert software, e.g., SPSS version XX]. Continuous variables were expressed as mean ± standard deviation and analyzed using the unpaired Student’s t-test. Categorical variables were compared using the Chi-square test or Fisher’s exact test, as appropriate. A p-value < 0.05 was considered statistically significant.

This study aimed to evaluate and compare the effects of nebulized dexmedetomidine and ropivacaine on perioperative hemodynamic stability, recovery characteristics, sedation, analgesia, and patient outcomes; the following results provide detailed insights into the clinical performance of both agents.

This table illustrates the demographic and sociocultural comparability between patients in the Dexmedetomidine (Group D) and Ropivacaine (Group R) cohorts. The mean age of participants was nearly identical between the two groups (42.3 ± 10.5 years in Group D vs. 41.8 ± 9.8 years in Group R; p = 0.74), reflecting a well-matched population. Gender distribution was balanced, with males representing 56% and 52% of Groups D and R, respectively. The socioeconomic status, assessed via the Kuppuswamy scale, revealed a proportional spread across the five social strata, again without significant intergroup variation (p > 0.05). Educational background was similarly distributed, with the majority of participants having attained secondary or graduate-level education. The uniformity across all demographic variables eliminates confounding effects and reinforces the internal validity of the study, ensuring that subsequent physiological and clinical outcomes can be more confidently attributed to the pharmacologic intervention rather than baseline disparities.

Table 1: Baseline Demographic and Sociocultural Characteristics of Study Participants

This table presents a detailed temporal analysis of hemodynamic responses across both intervention groups, starting from baseline through 20 minutes post-intubation. At baseline, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) values were statistically similar across both groups, validating a comparable starting point. Post-drug administration, however, Group D demonstrated significantly lower HR and blood pressure values compared to Group R, suggesting more effective sympatholytic action. These differences persisted and intensified during and after intubation, with Group D maintaining more stable and attenuated responses across all time points (p < 0.01 at every interval). Notably, at 1 minute post-intubation—a critical stress period—Group D had markedly lower HR (85.2 ± 9.4 vs. 88.6 ± 9.5) and MAP (102.6 ± 9.3 vs. 106.3 ± 9.5), indicating better cardiovascular control. The consistent hemodynamic attenuation in the Dexmedetomidine group supports its superior efficacy in blunting the stress response to laryngoscopy and intubation.

Table 2: Hemodynamic Changes Over Time (Group D vs. Group R)

The third table compares perioperative recovery dynamics, depth of sedation, and postoperative analgesia between the two groups. Group D showed faster emergence from anesthesia, evidenced by a shorter mean time to extubation (8.6 ± 1.2 min vs. 9.2 ± 1.5 min; p = 0.045) and quicker response to verbal commands. Time to full recovery was also marginally shorter in Group D. Importantly, sedation, assessed using the Ramsay Sedation Scale, was consistently higher in Group D in the immediate postoperative phase and throughout the early recovery window (up to 2 hours), with all time points showing statistically significant differences (p < 0.05). This indicates that Dexmedetomidine not only provides effective intraoperative sedation but also extends its calming effects postoperatively without delaying recovery. Furthermore, postoperative VAS scores were consistently lower in Group D, especially at 30 minutes, 1 hour, and 2 hours, suggesting enhanced analgesic synergy. These results collectively underscore the dual benefit of Dexmedetomidine in promoting smoother recovery and superior postoperative comfort.

Table 3: Comparison of Recovery Profile, Sedation Levels, and Postoperative Pain Scores

This table evaluates the safety profile and intraoperative pharmacologic consumption between the two groups. Both agents demonstrated excellent safety with no statistically significant differences in the incidence of adverse effects such as bradycardia, hypotension, nausea, vomiting, or shivering. However, Group D required significantly lower supplemental oxygen postoperatively at all measured intervals (p < 0.05), implying better respiratory dynamics and less airway reactivity. Intraoperative anesthetic consumption further highlighted the advantages of Dexmedetomidine; patients in Group D needed significantly lower doses of propofol, vecuronium, and isoflurane, indicating an anesthetic-sparing effect. This reduction not only improves drug economy but also reduces potential drug-related complications. Together, these findings affirm that nebulized Dexmedetomidine offers a favorable balance of efficacy and safety while minimizing the need for additional anesthetic agents and oxygen supplementation.

Table 4: Adverse Effects, Oxygen Requirement, and Intraoperative Anesthetic Use

In Table 5, patient-centered outcomes and intraoperative physiological metrics are compared. Satisfaction scores were slightly more favorable in Group D, with 44% reporting being “highly satisfied” versus 40% in Group R, though these differences were not statistically significant. SpO₂ levels remained stable and comparable across all perioperative time points in both groups, underscoring the respiratory safety of both agents. However, Group D exhibited lower intraoperative blood loss throughout all surgical phases, particularly after drug administration and intubation (p-values ranging from 0.046 to 0.038). This may reflect better hemodynamic control and vasoconstriction stabilization due to Dexmedetomidine’s alpha-2 agonistic action. These results align with other outcome measures suggesting Dexmedetomidine not only improves intraoperative physiological parameters but also enhances surgical field visibility by limiting blood loss, thereby contributing to both surgical ease and patient safety.

Table 5: Patient Satisfaction, SpO₂ Levels, and Intraoperative Blood Loss

The present study was designed as a comparative, prospective, and randomized trial to evaluate the efficacy of nebulized dexmedetomidine and ropivacaine in attenuating the hemodynamic stress response associated with laryngoscopy and endotracheal intubation in patients undergoing elective surgery under general anesthesia. By employing rigorous methodology and standardized monitoring, our objective was to establish which agent—dexmedetomidine or ropivacaine—offers superior cardiovascular stability, smoother recovery, better sedation, and analgesia, while minimizing intraoperative anesthetic requirements and adverse effects.

Demographically, both groups were comparable in terms of age, gender distribution, socioeconomic status (assessed via the Kuppuswamy scale), and education level. The mean age for Group D (Dexmedetomidine) was 42.3 ± 10.5 years and for Group R (Ropivacaine) was 41.8 ± 9.8 years (p = 0.74), confirming that patient selection bias was minimized. These findings are consistent with the study by Abd Elhafez NF et al⁹ where baseline age and gender were similarly distributed and not statistically significant across groups. Socioeconomic and educational parity further ensured that external sociodemographic factors did not confound the clinical outcomes, thereby strengthening the internal validity of our results. No prior literature was found specifically correlating these factors with anesthetic stress response, highlighting the originality of this demographic control.

Hemodynamically, both drugs provided adequate attenuation of the pressor response, though dexmedetomidine exhibited superior control. Baseline vitals were statistically similar (p > 0.8 for all parameters), aligning with observations by Singla A et al¹⁰ who reported comparable baseline vitals in both study groups. Following drug administration and induction, both groups showed statistically significant reductions in HR, SBP, DBP, and MAP, with Group D demonstrating more pronounced and consistent control, especially post-intubation. For example, at 1 minute post-intubation, HR and MAP in Group D were significantly lower than in Group R (p = 0.003), indicating that dexmedetomidine more effectively blunted sympathetic activation. This is congruent with results reported by Colaco NM et al¹¹, who observed lower HRs in dexmedetomidine-treated patients at all post-intubation intervals. The trend of better hemodynamic control with dexmedetomidine continued up to 20 minutes post-intubation, validating its prolonged alpha-2 agonistic action and sympatholytic effect.

Recovery characteristics also favored dexmedetomidine. Group D exhibited faster extubation (8.6 ± 1.2 vs. 9.2 ± 1.5 min; p = 0.045) and response times (10.4 ± 1.6 vs. 11.1 ± 1.9 min; p = 0.039). Though time to full recovery showed no significant difference, the trend still favored Group D. This early recovery profile is clinically advantageous, allowing for faster turnover in operative suites. Although we did not find direct references comparing these specific recovery parameters, the findings support dexmedetomidine’s known pharmacological profile of providing sedation without significant respiratory depression.

Postoperative sedation scores, as measured by the Ramsay Sedation Scale, were consistently higher in the dexmedetomidine group at all time intervals (p < 0.05), suggesting a deeper and more sustained sedative effect. Colaco NM et al¹¹ also observed significantly higher sedation scores in patients receiving dexmedetomidine, which supports our findings. Importantly, this sedative effect did not compromise recovery or increase oxygen requirement, indicating that dexmedetomidine offers a favorable sedation profile without affecting respiratory drive—a key consideration in anesthetic practice.

Analgesically, dexmedetomidine again outperformed ropivacaine. Postoperative VAS scores were lower in Group D at all measured intervals, reaching statistical significance at 30 minutes (3.2 ± 0.8 vs. 3.5 ± 0.8; p = 0.045), 1 hour (3.5 ± 0.7 vs. 3.8 ± 0.7; p = 0.039), and 2 hours (3.9 ± 0.6 vs. 4.2 ± 0.6; p = 0.032). These results suggest superior postoperative analgesia, likely due to dexmedetomidine's central modulation of nociceptive pathways. No relevant studies directly comparing VAS scores between nebulized dexmedetomidine and ropivacaine were found, positioning our study as a valuable addition to the literature.

Regarding safety, both agents showed comparable profiles with minimal adverse effects. Bradycardia and hypotension were slightly more prevalent in Group D but did not reach statistical significance (p > 0.7), consistent with expected pharmacodynamics. Postoperative oxygen requirements were significantly lower in Group D at all time points (p < 0.05), indicating improved respiratory efficiency or reduced work of breathing, possibly secondary to better analgesia and sedation. Again, we did not find published comparisons of postoperative oxygen requirements in the context of these two drugs, reinforcing the novelty of this observation.

The intraoperative anesthetic requirement analysis further underscored the benefits of dexmedetomidine. Group D required significantly less propofol (110.5 ± 15.2 vs. 118.2 ± 16.3 mg; p = 0.038), vecuronium (6.2 ± 1.1 vs. 6.5 ± 1.3 mg; p = 0.042), and isoflurane (1.1 ± 0.2% vs. 1.2 ± 0.3%; p = 0.045). This anesthetic-sparing effect reduces the total drug burden, potentially improving hemodynamic stability and minimizing drug-related side effects. These findings corroborate dexmedetomidine’s established role as a sedative adjunct that reduces anesthetic consumption without prolonging recovery.

Intraoperative blood loss was another parameter where dexmedetomidine offered modest advantages. At all measured intervals, Group D consistently recorded lower mean blood loss compared to Group R, reaching statistical significance post-drug administration, post-intubation, and at surgery end (p < 0.05). This could be attributed to better hemodynamic control, leading to less vasodilation and oozing. No prior studies directly compared nebulized dexmedetomidine and ropivacaine on this outcome, making our results a meaningful addition to perioperative management literature.

Lastly, patient satisfaction was similar across both groups, with the majority of patients reporting high levels of satisfaction. Despite dexmedetomidine offering superior clinical outcomes in multiple domains, patient-reported satisfaction did not significantly differ (p > 0.05). This may reflect the multifactorial nature of satisfaction, encompassing not just physiological but also psychological and procedural aspects of perioperative care.

In summary, this study demonstrates that nebulized dexmedetomidine provides superior attenuation of the hemodynamic stress response, offers better sedation and analgesia, reduces the requirement for intraoperative anesthetics and postoperative oxygen, and leads to less blood loss compared to nebulized ropivacaine. While both drugs are effective and safe, dexmedetomidine clearly provides a broader range of benefits in optimizing intraoperative and immediate postoperative patient management. These findings have important implications for clinical anesthesia practice, advocating the preferential use of dexmedetomidine in scenarios where modulation of stress response and perioperative stability are of paramount concern.

Limitations:
This study, while robust in design, has several limitations that may affect the generalizability and scope of its findings. Being conducted at a single center with a relatively small and homogeneous patient population (ASA Grade I–II, aged 20–60 years undergoing elective surgeries), the results may not be fully applicable to pediatric, geriatric, or high-risk populations. The lack of a placebo group and absence of blinding may introduce performance and selection biases. Additionally, only short-term postoperative outcomes were assessed, with no long-term follow-up for delayed complications or quality-of-life impacts. The exclusion of patients with difficult airways (Mallampati scores III or IV) further limits its applicability in more complex clinical scenarios. Moreover, technical variables such as nebulization technique and device consistency were not standardized or evaluated, and alternative routes of drug administration were not explored. These constraints highlight the need for broader, blinded, multicenter trials with longer follow-up to validate and expand upon these findings.

This study demonstrates that while both nebulized dexmedetomidine (Group D) and ropivacaine (Group R) effectively attenuate the hemodynamic stress response to laryngoscopy and intubation, dexmedetomidine consistently outperformed ropivacaine across multiple clinical parameters. Group D exhibited superior control over heart rate and blood pressure post-intubation, faster recovery times, more effective sedation and postoperative pain management, reduced oxygen requirements, and lower intraoperative anesthetic consumption and blood loss, all with a comparable safety profile. These findings suggest that nebulized dexmedetomidine offers a more efficient and clinically advantageous profile for enhancing perioperative stability and patient outcomes in ASA I–II adults undergoing elective surgery.

Recommendation:
Based on the results of this study, nebulized dexmedetomidine should be considered a preferred non-invasive premedication agent for attenuating intubation-related hemodynamic stress in elective surgical patients. Future research is recommended to validate these findings in larger, multicenter trials and across broader patient populations, including pediatric, geriatric, and high-risk individuals. Comparative studies involving different routes of administration, long-term follow-up for adverse effects, and inclusion of qualitative outcomes such as patient-reported comfort and quality of recovery would further strengthen the clinical applicability and evidence base for nebulized dexmedetomidine in modern anesthetic practice.

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