Dig Dis Sci

DOI 10.1007/s10620-016-4375-z

REVIEW

Airway Management During Upper GI Endoscopic Procedures:

State of the Art Review
Basavana Goudra1 • Preet Mohinder Singh2

Received: 5 August 2016 / Accepted: 3 November 2016

Ó Springer Science+Business Media New York 2016

Abstract With the growing popularity of propofol Keywords ERCP
Advanced endoscopy
Anesthesia

mediated deep sedation for upper gastrointestinal (GI) Airway devices endoscopy
Anesthesia tips endoscopy
endoscopic procedures, challenges are being felt and
appreciated. Research suggests that management of the
airway is anything but routine in this setting. Although Introduction
many studies and meta-analyses have demonstrated the
safety of propofol sedation administered by registered The growing popularity of deep sedation in patients
nurses under the supervision of gastroenterologists (likely undergoing gastrointestinal (GI) endoscopy has created
related to the lighter degrees of sedation than those pro- immense challenges to anesthesiologists, gastroenterolo-
vided by anesthesia providers and is under medicolegal gists, and airway/monitoring device manufacturers. Pro-
controversy in the United States), there is no agreement on viding deep sedation for these procedures requires a
the optimum airway management for procedures such as paradigm shift in the application of the knowledge and
endoscopic retrograde cholangiopancreatography. Failure resources. From the anesthesia provider’s stand point, it is
to rescue an airway at an appropriate time has led to dis- a state of ‘‘fish out of water’’—moving away from the
astrous consequences. Inability to evaluate and appreciate comfort of the operating room. Apart from the unfamil-
the risk factors for aspiration can ruin the day for both the iarity of the anesthetizing location, absence of a secure
patient and the health care providers. This review apprises airway is a critical concern. Gastroenterologists have
the reader of various aspects of airway management rele- clearly benefited from deep sedation. It allows performing
vant to the practice of sedation during upper GI endoscopy. complicated procedures with relative ease. However, added
New devices and modification of existing devices are dis- cost of anesthesia providers is a major constraint. This
cussed in detail. Recognizing the fact that appropriate could have been one of the reason, Sedasys, the much
monitoring is important for timely recognition and man- advertised robot failed [1–3]. From a practical standpoint,
agement of potential airway disasters, these issues are securing an airway in a patient with a gastroscope in situ is
explored thoroughly. impossible without endotracheal intubation. More research
is needed in the area of airway devices used in GI endo-
scopy. Finding a reliable respiratory monitor is another
area of ongoing research. The present review aims to
& Basavana Goudra provide the readers succinct information on the effects of
[email protected]
sedative medications on the anatomy and physiology of the
Preet Mohinder Singh airway, followed by a state of the art discussion about the
[email protected]
devices available, old and new, to secure an otherwise
1
Perelman School of Medicine, Hospital of the University of ‘‘insecure’’ airway in the setting of upper GI endoscopy.
Pennsylvania, Philadelphia, PA, USA Several improvisations in the use of existing devices are
2
Department of Anesthesia, All India Institute of Medical also presented. The review is intended as much for anes-
Sciences, New Delhi 110029, India thesia providers as gastroenterologists.

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 Dig Dis Sci

Anatomy and Physiology of the Upper Airway

An understanding of the upper airway anatomy including

many variants of ‘‘normal’’ is crucial for safe adminis-
tration of sedatives. It should be borne in mind that
majority of adverse outcomes including cardio-respira-
tory arrests are related to challenges in airway manage-
ment [4–6]. Unlike anesthesia involving an endotracheal
intubation, where securing the safe airway is predomi-
nantly during induction and extubation, in GI endoscopy,
it is an ongoing process and lasts as long as the pro-
cedure lasts.

Effects of Sedation on the Upper Airway Fig. 2 Figure demonstrating relevant airway anatomy along with
Physiology situation of airway obstruction. The figure also demonstrates common
site of airway collapse in a sedated spontaneously breathing patient
During awake state, negative intraluminal pressure in the
pharynx is balanced by the tone of the upper airway Management of the Upper Airway
musculature [7]. This prevents closure of the upper airway.
The velopharyngeal mechanism consists of a muscular Hypoxemia manifesting with low oxygen saturation is
valve that extends from the posterior surface of the hard common during upper GI endoscopic procedures, espe-
palate to the posterior pharyngeal wall and includes the soft cially ERCP. The severity and the frequency of such
palate (velum), lateral pharyngeal walls (sides of the desaturation depend on the criterion used to define such an
throat), and the posterior pharyngeal wall (back wall of the event.
throat). The velopharyngeal mechanism creates a tight seal Approach to prevention and management of hypoxemia
between the velum and pharyngeal walls to separate the is as varied as the criteria used to define the event.
oral and nasal cavities for various purposes, including Increasing supplemental oxygen, insertion of a nasal air-
speech. Velopharyngeal closure is accomplished through way, various airway manoeuvers, endoscope withdrawal
the contraction of several velopharyngeal muscles and followed by positive pressure ventilation, insertion of
includes levator veli palatini, musculus uvulae, superior laryngeal mask airway, and rarely endotracheal intubation
pharyngeal constrictor, palatopharyngeus, palatoglossus, are some of the approaches employed. It is not uncommon
and salpingopharyngeus. The mechanism is illustrated in to attempt an aggressive approach such as endotracheal
Fig. 1. intubation early in the management of hypoxemia. How-
Velopharynx is the most common site of collapse during ever, such an approach might cause more harm than good,
anesthesia, as during natural sleep. Contrary to previous if inappropriately chosen or executed [9]. Attention to more
belief, obstruction of the oropharynx due to retrolingual basic tenets of airway management is likely to save more
collapse (tongue falling back) is the second commonest lives than measures such as laryngeal mask airway inser-
cause of collapse [8] (Fig. 2). tion or endotracheal intubation. To be successful, these

Fig. 1 Velopharyngeal
mechanism-demonstrating how
the negative pressure inside the
airway during spontaneous
breathing predisposed to airway
collapse and the tone of
pharyngeal muscles prevents the
same

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Dig Dis Sci

lifesaving airway maneuvers with appropriate devices need pharyngeal space. However, the endoscope itself can also
to be employed at pertinent times. It is also essential that act as an upper airway stent (Fig. 3).
sufficient time is allowed for these measures to yield A frequent observation during upper GI endoscopy,
results, if clinically judged to be effective. As an example, especially under propofol sedation is thoracoabdominal
if the ventilation is judged to be effective as evidenced by asynchrony. Commonly caused by airway obstruction, it is
the chest excursions, it is advisable to allow sufficient time possibly due to deeper levels of sedation associated with
for the pulse oximeter derived saturation to return to propofol in comparison to intravenous conscious sedation.
baseline. Ignoring the lag time inherent in the pulse Management involves chin lift, jaw thrust, and neck
oximeter, might fool the physician to abandon an effective extension. However, rarely these maneuvers may worsen
ongoing approach, in favor of an endotracheal intubation, the obstruction instead of relieving it. In the absence of
which is fraught with unexpected consequences in an CPAP, chin lift and jaw thrust can reduce the posterior
emergency setting. pharyngeal space, potentially worsening upper airway
obstruction [13]. Unfortunately, it is not easy to apply
CPAP in the absence of an airtight airway. The devices
Prone and Semi-Prone Positioning which can possibly allow application of CPAP are dis-
cussed later.
Endoscopic procedures like ERCP are generally performed The effect of positioning on the airway obstruction is
with the patient in prone/semi-prone position, thereby important and supine position is not ideal from this point.
posing additional challenges, especially in an unintubated Fortunately, most upper GI endoscopic procedures are
patient. Although gravitational forces prevent airway col- performed in the lateral position. Lateral position in asso-
lapse, airway complication rates remain high [6, 10]. Lack ciation with airway maneuvers is known to open the upper
of familiarity and absence of a plan in the event of airway [14, 15]. Although these studies were done in
hypoxemia might be the contributing factors. Unexpected children, the results are valid in adults in the absence of
technical challenges might increase the risk of losing the anatomical abnormality.
airway. One must, however, keep in mind that unlike sur- Finally, the optimal head positioning during sedation
gical procedures, endoscopic procedures can be aborted to especially deep sedation during upper GI endoscopy is
facilitate airway intervention at almost no notice. To patient dependent. Adults with obstructive sleep apnea
enhance patient safety, continuous oxygen supplementation (OSA) benefit from a sniffing position [16, 17]. Receding
(preferably via a nasopharyngeal airway) must always be chin, obese neck, and a body mass index (BMI) of over
used. Simple manipulations such as assisting ventilation
(after turning the patients head or the patient himself to the
side) and a firm chin lift could be lifesaving. It goes
without saying that it is important to remain vigilant and
intervene for any airway compromise with bag-mask ven-
tilation or emergency endotracheal intubation. The airway
complication rates are proportional to length of the pro-
cedures and constant vigilance is the key.

Maneuver Chin Lift, Jaw Thrust, and Neck

Extension

Chin lift is known to cause widening of the entire pha-

ryngeal space, most pronounced between the tip of the
epiglottis and posterior pharyngeal [11]. In this study
involving children, wherein the measurements were done
using magnetic resonance imaging, upper airway dimen-
sions were preserved. In a similar study involving children
with adenotonsillar hypertrophy and stridor, chin lift with
CPAP (continuous positive airway pressure) relieved stri-
dor under anesthesia [12]. The situation in upper endo-
Fig. 3 Mechanism of an endoscope stenting the airway open. The
scopy may not be exactly comparable due to the presence endoscope prevents the collapse of the airway at the pharyngeal level
of endoscope, which can compromise the posterior despite negative pressure in the pharynx during spontaneous breathing

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30 kg/m2 in association with OSA can be a cause of both

difficult mask ventilation and intubation. Pharyngeal air-
way collapsibility is increased in this subgroup of patients
presenting for endoscopy (Fig. 4). Closing pressure,
defined as the pharyngeal pressure at which the posterior
pharynx collapses, causing upper airway obstruction is
normally sub-atmospheric. However, in patients with OSA
it is 2 ± 3 cm H2O. This can be overcome by adapting a
sitting sniffing position (Fig. 5). CPAP is another effective
way to overcome such an obstruction. However, it is
essential to have means of establishing positive pressure
ventilation, if CPAP is ineffective. Jaw thrust helps to pull
the tongue forward due to the anatomical link between the
two. However, it is not necessarily accompanied by an
increase in velopharyngeal space. A combination of
Fig. 5 Figure demonstrating the ideal laryngoscopy position:‘‘Sniff-
maneuvers is probably more important than any single ing the morning air’’
measure and it is important to constantly evaluate their
effectiveness and alter the approach depending on the the required standards. Many airway devices are available/
outcome. being developed to fill the void that can enhance both
It is also important to realize that these maneuvers can patient safety and procedural ease. Airway devices aim to
only applied after withdrawal of the endoscope. Timely provide supplemental oxygen in many unique ways to
endoscope withdrawal and efficient institution of these prevent procedure related desaturation episodes. We have
measures are critical to their success. discussed both contemporary and future devices in the
Increasing complexity of GI procedures has set chal- succeeding paragraphs.
lenges for anesthesia providers to deliver high quality care
without compromising safety. Technological advance- Face Masks
ments in the field of anesthesia have tried to keep pace with
These are extra-oral devices that fit along the facial contour
to supplement oxygen and/or drive positive pressure ven-
tilation. One of the prerequisite of these masks is to
accommodate the upper endoscope while the device is in
place.

Panoramic Face Mask

Increasing the concentration of inspired oxygen is a simple,

yet effective strategy. It is known to decrease the incidence
of hypoxemia in patients undergoing upper GI endoscopy.
Panoramic face mask (Fig. 6a) is a modification of the
simple face mask and uses a reservoir bag to deliver high
inspiratory oxygen. Combination of high volume reservoir
and the a one-way valve can provide up to 80–90 %
inspired oxygen with negligible rebreathing [18]. The
contours of the mask fit the human face closely preventing
any leaks around the face. Another unique feature of the
mask is a special port that may be used to measure exhaled
CO2 (and derive capnograph waveform). As a result, con-
Fig. 4 Pharyngeal collapse in a morbidly obese patient around the tinuous monitoring of respiration can be achieved. The
endoscope. These patients due to propensity for obstructive sleep panoramic mask has two resealable ‘‘self healing ports’’
apnea generate higher negative airway pressure (to overcome
that can be used to introduce gastroscope (oral port) or the
obstruction)—this increased negative pressure further precipitates
airway collapse. Also, peri-pharyngeal fat is also increased that flexible fibreoptic bronchoscope (nasal port). During the
enhances airway collapse upper GI endoscopy, the oral port allows almost

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Fig. 6 a Panoramic face mask. b Endoscopy mask. c DEAS mask

frictionless entry of the scope into the mouth and the nasal coupled with an anesthesia workstation, inhalational agent
port remains sealed with a biocompatible glue. The oral based anesthesia can also be provided using these masks.
port slit allows scopes of various sizes to pass through with These masks are available in multiple sizes varying from
minimal leaks around the port, thus a single adult size can pediatric to adult mask. Despite above advantages these
be used in patients with variable demographic profiles. masks are still not the most ideal airway devices for GI
Prior to the use of the mask, it must be ensured that the endoscopy. Other than logical possibility of facial pressure
oxygen supply is open and the reservoir bag is inflated. The skin necrosis, they offer no protection against aspiration.
manufacturer warns that if inflow is missing, it can lead to Any positive pressure ventilation used with them increases
detrimental hypoxia. Panoramic mask can be used for this risk further.
procedures performed under propofol sedation; however,
maintenance of spontaneous breathing is essential is criti-
cal for the success of the mask. In addition to the upper GI DEAS Endoscopic Mask
endoscopy, the manufacturer recommends the use of this
mask in flexible fibreoptic bronchoscopy, procedures under DEAS endoscopy mask (Fig. 6c) is a modification of the
sedation, and during monitored anesthesia care. endoscopy mask. It has all the advantages of the conven-
tional endoscopy mask, but has a separate port for measuring
end tidal carbon-dioxide. An additional port for measuring
Endoscopy Mask the inspiratory pressure is also present. Both these mea-
surements enhance the safety (CO2 increases the ability to
An endoscopy mask addresses the limitations of the detect the apnea) and allow better control of patient’s ven-
Panoramic face mask. It has a leak proof cushioned seal tilation during the upper GI endoscopy. The mask is fitted
along the facial contour that allows positive pressure ven- with an expandable flexible membrane that seals around
tilation in deeply sedated patient (Fig. 6b). Using an almost any size of endoscope preventing leaks during the
endoscopy mask both inspired oxygen concentration and procedure. Similar to a conventional endoscopic mask it has
their inspiratory breathing pressure (or ventilatory assis- a universal 22 mm port that can be connected to a standard
tance) can be regulated. An endoscopy mask allows breathing circuit or the closed circuit of an anesthesia
delivery of nearly 100 % oxygen. It may be used in com- workstation. It also suffers similar limitations because of its
bination with a non-rebreathing circuit (such as a circle inability to prevent airway obstruction or aspiration.
system) or a portable breathing system such as Mapleson
C. Various minor modifications in these masks increase
their practical utility. Endoscopy mask with hooks can be Airway Devices
used with a harness. Masks with multiple re-sealable ports
can allow the introduction of endoscope orally or nasally Nasopharyngeal Airway
(for bronchoscopy). Cushioned edges allow better fit
around the anatomical contours of the face and allow leak Nasopharyngeal airway is inserted via the nares and helps
proof interment positive pressure delivery if needed. When to bypass upper airway obstruction (Fig. 7a).

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Nasopharyngeal airway has a unique role in GI endoscopy It is recognized that the use of nasopharyngeal airway
as it can be used even in patients undergoing upper GI and a Mapleson C breathing system in the manner descri-
endoscopy. It is better tolerated by the patient and is less bed above is neither routine nor standard of care. Yet, in
traumatic. In our own retrospective review, use of the current practice of providing deep sedation by anes-
nasopharyngeal airway during endoscopy to provide CPAP thesia providers, it is essential to be prepared for rare
reduces the hypoxemic complications significantly. events of severe hypoxemia and have a plan to manage
Timing of insertion of the nasopharyngeal airway is of them.
profound importance. We typically induce with propofol
preceded by fentanyl or a similar short acting opioid. The Gastrolaryngeal Tube
dose is variable and depends on the patient’s age, weight,
height, comorbidity, and medication history, all of which A gastrolaryngeal tube is a specialized conduit
influence the pharmacokinetics and pharmacodynamics, designed to secure airway during the complex gas-
the variability of which is 300–400 % [19, 20]. We typi- trointestinal endoscopic procedures in adults. It allows
cally proceed with 1–1.5 mg/kg, although the dose may simultaneous use of gastroscope via a separate channel
need to be drastically reduced in elderly patients. Propofol built within the tube (Fig. 8a). The tube has two cuffs,
is preceded (1–2 min before) with fentanyl 25–50 mcg for the distal one inflates in the esophagus-preventing the
analgesic, propofol sparing, and antitussive effects. Fen- regurgitation of gastric contents (once the pressure
tanyl is especially important in patients undergoing increases inside the stomach). The second cuff lies
advanced endoscopic procedures including ERCP. An proximally and inflates to block air leak via the naso/
infusion of propofol at about 120–150 mcg/kg/min follows. oropharynx. In between these cuffs the tube has mul-
Preserving the patency of the upper airway and mainte- tiple perforations that lie adjutant to the larynx. These
nance of spontaneous ventilation along with suppression of holes are connected to the ventilating channel (extra-
the cough reflex are all of vital importance. At the peak oral) and allow the institution of positive pressure
clinical effect of propofol, signaled by loss of eyelash ventilation (if required). This tube has a unique
reflex, unresponsiveness, and sometimes apnea, a nasal advantage for upper GI endoscopy as it not only
trumpet is typically inserted and connected to a Mapleson increases the space for maneuvering the gastroscope,
C breathing system (Fig. 7b). At the peak of sedation but also can help in the insertion of gastroduodeno-
depth, endoscope is introduced, which also provides suf- scope by guiding it into the esophagus. The ventilating
ficient stimulation to initiate (if patient were to be apneic) port provides a connection for capnography. As a
and sustain spontaneous ventilation. Post procedure dis- result, both monitoring and control on ventilation can
comfort is rare, other than mild throat irritation; therefore, be achieved reliably. The tube is recommended for use
we limit the dose of fentanyl to about 100 mcg, unless the in complex procedures like ERCP, PEG (especially in
patient is on chronic opioid therapy or other reasons. patients with neurological ailments).

Fig. 7 a Nasopharyngeal airway. b Mapleson C circuit connected to the nasopharyngeal airway

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allow it to be secured using an atraumatic harness. The

intra-oral part of the bite block has an optional soft atrau-
matic airway flange. This serves a dual purpose: prevents
airway obstruction and also helps to guide the gastroscope
into the esophagus via the ridges on the airway flange.
Taking advantage of a stretchable silicone seal, different
size endoscopes can be introduced with minimal leakage.
Ports on this bite block allow for positive pressure venti-
lation (and monitoring ventilation via bag movements) and
suction of airway secretions.

Hague Airway

The Hague airway is another modification of the conven-

tional bite block. It has ports for providing high flow
oxygen during the procedure and also a port for measure-
ment of EtCO2 (allowing to monitor the patient’s breath-
ing). This bite block can also be fitted to patients mouth by
virtue of stretchable plastic straps. It is limited in its ability
to prevent airway obstruction or to provide assisted posi-
tive pressure ventilation in deeply sedated patients.

Safety Guard

The safety guard is a bite block that provides free access to

the mouth for endoscopy (Fig. 8c). The guard, like a ton-
gue depressor prevents airway obstruction during the pro-
cedure. An oxygenation channel opens intra-orally in close
Fig. 8 a Gastrolaryngeal tube. b Goudra bite block. c Safety guard proximity to the vocal cords and thus helps to provide high
bite block. Written permission/consent to publish the images is FiO2 during the sedation. An integrated connection allows
obtained from the patients were appropriate (Figs. 8, 9)
monitoring of EtCO2 for any possible apnea during
sedation.
Bite Blocks
Selection of the Device
Bite blocks are airway devices that assist the endoscopist to
introduce the gastroscope into the oral cavity, and they Having discussed the available devices and management
simultaneously prevent the patient from biting the scope. options, it is helpful to understand the situations in which
Over the years, improvements in the design of the bite to employ them. Clearly, any patient with a risk of aspi-
blocks have added features that have improved patient ration (bleeding, emergency, drainage of pesudocyst, gas-
safety. Bite blocks now have built-in airway-like features tric outlet obstruction, removal of foreign body, pharyngeal
and can prevent airway obstruction during sedation. Vari- pouch) would necessitate endotracheal intubation. Addi-
ous ports within the airways help to supplement oxygen to tionally, patients with anticipated difficult airway, espe-
the patient. Modern bite blocks also incorporate suction cially difficult mask ventilation might benefit either from
ports that clear airway secretions without interrupting the intubation or minimal sedation. In the remaining, the large
endoscopic procedure. majority of non-advanced endoscopic procedures may be
safely performed with an oxygen cannula. We recommend
Goudra’s Bite Block the use of a nasal airway connected to a Mapleson
breathing system for all advanced endoscopic procedures,
Goudra’s bit block is a unique innovation that incorporates including ERCP. Availability of a portable breathing sys-
all the features of an ideal bite block with an airway. The tem and both nasal and oral airways is essential for all
cushioned external part fits and seals around the oral cavity procedures and at all times. A panoramic face mask can
(Fig. 8b). The anesthesia provider does not need to hold the effectively replace a nasal cannula and assure high inspired
bite block physically during the procedure, as the hooks oxygen delivery with the convenience of an end tidal

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carbon dioxide monitor. DEAS mask and endoscopy mask Impedance Monitoring
has the added advantage of applying positive pressure
ventilation. While a safety guard bite block might displace This relies on the detection of actual physical movement of
the tongue, the Goudra bite block allows positive pressure the chest/abdominal wall. Impedance technology is incor-
ventilation. However, an awake person might not tolerate porated into the ECG electrode system to estimate the
the insertion of a bite block with an airway. It should be breathing rate. With each breath (inspiration) the thoracic
borne in mind that as demonstrated in Fig. 3, in the cage volume changes, thereby altering alters the electrical
majority, the endoscope acts as an oropharyngeal airway, properties like capacitance and resistance of the thoracic
and additional airway is unnecessary. A gastrolaryngeal wall [22]. ECG electrodes sense the small change in
tube might be a useful device during advanced endoscopic electrical conductance resulting from above alterations and
procedures in experienced hands. report a breathing rate It often is not very reliable due to
electrical interference and may be affected by patient
Monitoring movements. Another limitation is seen during upper airway
obstruction when the chest walls move without actual
It is an understatement to say that adverse event rates inflow of air. Newer impedance monitors (independent of
during GI endoscopic procedures under deep sedation are ECG electrodes) have two sensors. They detect whether
at least equal to, if not more than. those of general anes- chest and abdomen move in phase (un-obstructed breath-
thesia [4–6]. Hypoxemia remains the dominant cause of ing) or out of phase (obstructed breathing).
increased morbidity and mortality. These events are best Many studies have used pulse oximetry as a substitute
preempted than treated. As a first step, appropriate moni- for breathing monitoring. We however recommend against
toring of both ventilation and oxygenation is important. its routine use for this purpose. Saturation only begins to
Our own study showed that majority of adverse events fall once apnea has persisted long enough to consume the
during the endoscopy occur as a result of ventilation related oxygen stored in functional residual capacity. Thus, the
issues. Even for the most experienced sedation provider it warning for required intervention is delayed. No available
may be difficult to titrate the depth of sedation and thus monitoring is perfect and vigilance is the key for preven-
prevent over sedation. Further, the ASA standards of basic tion of respiratory complications during endoscopy.
minimum monitoring applies to patients undergoing pro-
cedures under deep sedation. However, continuous moni- Acoustic Respiratory Monitoring
toring of breathing is one of the most critical aspect of
monitoring for which a satisfactory tool is not yet The available methods for monitoring respiration during
available. upper GI endoscopy have significant limitations. Pulse
oximetry, for example, is found to detect only 50 % of
End Tidal Carbon Dioxide Monitoring apnea or inadequate ventilation events [23]. Additionally,
pulse oximetry (SpO2) is a lagging indicator of hypoventi-
End tidal carbon dioxide monitoring or capnography is lation especially in patients receiving supplemental oxygen
widely available and easy to use. It relies on the exhaled [24]. Thus, valuable time could be lost in implementing
CO2 measurement to determine the expiratory phase of corrective measures, thereby risking severe hypoxemia and
the breathing cycle. However, during endoscopy it does possible cardiorespiratory arrest. Impedance pneumogra-
have many limitations due to air dilution by the high fresh phy, on the other hand, requires significant chest wall
gas [21]. In fact, the reliability and accuracy was least for movement to record respiration and continues to show
capnography, when compared to acoustic respiratory active respiratory activity in patients breathing against a
monitor and impedance pneumography. Thus, it is rec- partial or completely closed glottis. Patient movement
ommended that end tidal CO2 should not be a sole ven- artifacts (to facilitate the gastroscope insertion, for exam-
tilation monitor during upper GI endoscopy. Furthermore, ple) can also adversely affect its accuracy. Acoustic respi-
it should also be kept in mind that it is more of a qual- ratory monitor continuously measures respiratory rate using
itative monitor (assures patient is breathing), but has poor an adhesive sensor with an integrated acoustic transducer
quantitative value (does not provide information on tidal applied on the patient’s neck. Although it suffers from many
volume or adequacy of ventilation). Capnography ports limitations, including signal noise due to pharyngeal muscle
are available on many specialized airway devices movements, in adult patients undergoing advanced GI
designed for endoscopy which might improve the relia- endoscopic procedures, it was more accurate and provided
bility. More specialized respiratory monitoring with par- apnea detection, which was similar or better than EtCO2 or
ticularly higher specificity are making way into the impedance pneumography, two standard of care monitors in
endoscopy field. the endoscopy suite [21].

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