title: Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy.
abstract: BACKGROUND
  Recommendations from the American Society of Anesthesiologists suggest that monitoring for apnea using the detection of exhaled carbon dioxide (capnography) is a useful adjunct in the assessment of ventilatory status of patients undergoing sedation and analgesia. There are no data on the utility of capnography in GI endoscopy, nor is the frequency of abnormal ventilatory activity during endoscopy known. The aims of this study were to determine the following: (1) the frequency of abnormal ventilatory activity during therapeutic upper endoscopy, (2) the sensitivity of observation and pulse oximetry in the detection of apnea or disordered respiration, and (3) whether capnography provides an improvement over accepted monitoring techniques.
  
  
  METHODS
  Forty-nine patients undergoing therapeutic upper endoscopy were monitored with standard methods including pulse oximetry, automated blood pressure measurement, and visual assessment. In addition, graphic assessment of respiratory activity with sidestream capnography was performed in all patients. Endoscopy personnel were blinded to capnography data. Episodes of apnea or disordered respiration detected by capnography were documented and compared with the occurrence of hypoxemia, hypercapnea, hypotension, and the recognition of abnormal respiratory activity by endoscopy personnel.
  
  
  RESULTS
  Comparison of simultaneous respiratory rate measurements obtained by capnography and by auscultation with a pretracheal stethoscope verified that capnography was an excellent indicator of respiratory rate when compared with the reference standard (auscultation) (r = 0.967, p < 0.001). Fifty-four episodes of apnea or disordered respiration occurred in 28 patients (mean duration 70.8 seconds). Only 50% of apnea or disordered respiration episodes were eventually detected by pulse oximetry. None were detected by visual assessment (p < 0.0010).
  
  
  CONCLUSIONS
  Apnea/disordered respiration occurs commonly during therapeutic upper endoscopy and frequently precedes the development of hypoxemia. Potentially important abnormalities in respiratory activity are undetected with pulse oximetry and visual assessment.
authors.affiliation: Center for Pancreaticobiliary Diseases, Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Vargo
authors.forename: Gregory
authors.initials: G
authors.lastname: Zuccaro
authors.forename: John A
authors.initials: JA
authors.lastname: Dumot
authors.forename: Darwin L
authors.initials: DL
authors.lastname: Conwell
authors.forename: J Brad
authors.initials: JB
authors.lastname: Morrow
authors.forename: Steven S
authors.initials: SS
authors.lastname: Shay
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019296:Capnography; D003196:Computer Graphics; D001330:Electronic Data Processing; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects*; D005260:Female; D005767:Gastrointestinal Diseases / Q000601:surgery*; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D010092:Oximetry; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology*; D012137:Respiratory System / Q000503:physiopathology*; D012680:Sensitivity and Specificity; D013997:Time Factors; D014796:Visual Perception