REVIEW
Cardiorespiratory complications of digestive endoscopy
not related to sedation
Juan Antonio Vázquez Rodríguez, Carmen Molina Villalba and Eva Martínez Amate
Clinical Management Unit of Digestive Diseases. Hospital de Poniente. El Ejido, Almería. Spain
Received: 29/01/2020 · Accepted: 10/02/2020
Correspondence: Juan Antonio Vázquez Rodríguez. Clinical Management Unit of Digestive Diseases. Hospital de
Poniente. Ctra. Almerimar, 31. 04700 El Ejido, Almería. Spain. e-mail: juavazrod@hotmail.com
ABSTRACT
Although digestive endoscopy is considered to be a safe
procedure, both the growing complexity of the techniques
and the underlying diseases of patients increase the risk
of adverse events during the procedure. Cardiorespiratory
events are the most frequent complications, and can occur
in patients with or without sedation, although they appear
more often when the patient is sedated. The body’s phy-
siological response to stress is what causes these adverse
events, which are generally mild and transient, although
they can be serious. They are more frequent in patients
with cardiopulmonary diseases, which logically increase
risk. The autonomic nervous system, through its sympathe-
tic and parasympathetic branches, is primarily responsible
for these alterations. Patients with asthma or chronic obs-
tructive pulmonary disease have a higher risk of hypoxe-
mia, bronchospasm, and arrhythmia during the endoscopic
procedure. Patients with arrhythmia and ischemic heart
disease have a higher risk of myocardial ischemia and heart
rhythm disturbances. The risk of adverse events during the
procedure can be reduced by reviewing the patient’s medi-
cal history along with a basic clinical examination before
endoscopy. A brief interrogation about symptom control
can also help the safety of endoscopy.
Keywords: Digestive endoscopy. Endoscopy complications.
INTRODUCTION
Digestive endoscopy (DE) currently plays a fundamental
role in the diagnosis and treatment of multiple diseases of
the digestive tract, and is considered as a very safe proce-
dure (1,2). However, increased complexity, both in terms of
techniques and patients themselves (elderly, pluripatholo-
gical, receiving anticoagulant and/or antiplatelet therapy),
carries a greater risk of suffering adverse events during
the procedure.
Conflict of interest: the authors declare no conflict of interest.
1130-0108/2021/113/3/202-206 • REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
© Copyright 2021. SEPD y © ARÁN EDICIONES, S.L.
Most of the publications that analyze the complications of
DE focus on those related to sedation and the technique
itself, especially in terms of therapeutic procedures (perfo-
ration, hemorrhage, etc.), while those evaluating the car-
diorespiratory complications (CRC) of DE per se are less
common, older, and less known but no less important for
the endoscopist. The objective of this review is to give the
endoscopist an overview of the main CRC of DE, which may
lead to gaining a better understanding of their pathophy-
siology and risk factors, in order to establish measures to
prevent them.
Various studies have evaluated the risk of CRC during
DE, establishing a frequency between 0.017 % and 0.54 %
(2-5). More recently, Sharma et al. estimated a frequency
of CRC close to 1 %, with this group representing more
than half of the adverse events recorded during a DE pro-
cedure, in addition to being the primary cause of procedu-
re-related mortality (6). These discrepancies between the
results of different studies (due to their design, definition
of CRC, population studied, and sedation status) make
it difficult to assess the real incidence of these adverse
events (7).
The pathophysiological changes most frequently recorded
during DE are those that occur in blood oxygen saturation
levels, blood pressure, or heart rate, which in most cases
are mild and transient but may become fatal (6-10) (Table 1).
These changes may appear in healthy subjects, triggered
by the body’s physiological response to the stress caused
by the endoscopic (invasive) procedure, or else occur in
patients with morbidities that play a role as risk factors
(8,9,11-13). In addition, there are risk factors inherent to the
procedure itself, such as duration or the use of endoscopes
Vázquez Rodríguez JA, Molina Villalba C, Martínez Amate E. Cardiorespiratory
complications of digestive endoscopy not related to sedation. Rev Esp Enferm
Dig 2021;113(3):202-206
DOI: 10.17235/reed.2020.6917/2020
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 Cardiorespiratory complications of digestive endoscopy not related to sedation 203

Table 1. Principal cardiorespiratory complications of
digestive endoscopy
Hypertension Hypoxemia
Hypotension Hypercapnia
Sinus tachycardia Aspiration pneumonia
Sinus bradycardia
Extrasystoles
Atrial fibrillation
Supraventricular tachycardia
Ventricular tachycardia
Myocardial infarction
Table 2. Principal risk factors for the appearance of
cardiorespiratory complications during digestive
endoscopy procedures
Risk factors
Age ≥ 65 years Prolonged procedure time
ASA ≥ 3 Supine position
Oxygen saturation < 95 % Difficult esophageal intubation
Pre-existing cardiopulmonary
Emergency procedure
disease
Use of sedative medication
with larger diameters (9,10). Table 2 summarizes the main
risk factors for the occurrence of CRC during DE.
In a retrospective study that analyzed events that requi-
red cardiopulmonary resuscitation (CPR) maneuvers in the
endoscopy units of several South Korean hospitals, it was
observed that most events occurred during the endoscopic
procedure, particularly during the exploration of the upper
digestive tract. In addition, these events were generally due
to an exacerbation of an underlying disease, with respira-
tory failure being the main trigger of CPR (14). The authors
estimated an incidence rate of 15 cases per 100,000 endos-
copies for events that required CPR, with a mortality rate of
6 per 100,000 cases for these events (14).
PATHOPHYSIOLOGICAL CHANGES
DURING DIGESTIVE ENDOSCOPY
Hypoxemia is one of the main adverse events that may
occur during DE, mainly during upper GI endoscopy (EGD),
and is aggravated by endoscopes with a larger diameter,
the existence of underlying cardiopulmonary diseases,
as well as the use of sedative medication (9,11-13,15). It
is thought that the passage of the endoscope produces a
partial obstruction of the airway, which leads to desatura-
tion and hypoxemia, even in subjects without other risk
factors (9,16). In addition to those previously mentioned,
Alcain et al. identified as predictive factors for hypoxemia
during DE a baseline saturation of less than 95 %, repeated
esophageal intubation attempts, emergency procedures,
and an American Society of Anesthesiology (ASA) classifi-
cation greater than or equal to three (17).
The autonomic nervous system (sympathetic and parasym-
pathetic) plays a fundamental role in the body’s response
to endoscopic procedures. The stimulation of receptors
at the level of the oropharynx and hollow viscera, in the
case of DE, mainly by mechanical stimuli, triggers diffe-
rent physiological responses (18,19). Best known is the
vasovagal response, which through the parasympathetic
nervous system (PSNS) causes bradycardia and hypoten-
sion in response to the mechanical stimulus produced by
the passage of the endoscope through the oropharynx or
the hollow abdominal viscera distended with air insuffla-
tion (8,18,19). On the other hand, the stress to which the
organism is subjected during the procedure, or the anxiety
that endoscopy generates in the patient, triggers an activa-
tion of the sympathetic nervous system (SNS), in charge
of preparing the organism for a stress situation, causing
tachycardia, hypertension, and sweating (11,18,19). The
pain that sometimes appears during the procedure usually
causes a sympathetic response, although it can also pro-
duce a parasympathetic response through the vasovagal
reflex (10,19).
The changes in heart rhythm that occur during DE are con-
sidered to be a consequence of the autonomic nervous
response and hypoxemia caused by the passage of the
endoscope through the oropharynx (9,11,20). The altera-
tion of the sympathetic-vagal tone favors the appearance
of arrhythmias, and hypoxemia induces cardiac ischemia,
which in turn favors the appearance of electrical changes
(13,21,22). However, some studies have shown that there
is no significant correlation between hypoxemia and the
development of electrocardiographic abnormalities, con-
cluding that their appearance is due to increased cardiac
workload (11,12). These studies coincide in identifying
patients with underlying heart or respiratory diseases as
a population at risk for the development of arrhythmias
during the procedure (9,11,12).
RECOMMENDATIONS FOR ENDOSCOPIC
PROCEDURES IN HIGH-RISK PATIENTS
Before performing any endoscopic procedure, it is neces-
sary to categorize the patient according to the risk of deve-
loping a cardiorespiratory event during DE. This requires
a review of their medical history and a basic clinical exa-
mination. In addition to this, for those that are considered
to be high-risk patients (cardiac, bronchial conditions), it
is advisable to conduct a brief interview focusing on the
presence of symptoms in the hours before the procedure,
current medical treatment, and even the date of the last
follow-up visit with the specialist.
The physical status classification system of the ASA is
widely used to assess the status of a patient’s health in
order to estimate their surgical risk (23) (Table 3). The STOP-
BANG questionnaire also helps to easily and quickly identi-
fy patients with obstructive sleep apnea syndrome (OSAS)
(24) (Table 4). These two tools help alert the endoscopist
at the endoscopy room about those patients who have a
higher risk of developing adverse events during the endos-
copic procedure.

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204
Table 3. American Society of Anesthesiology (ASA)
Classification System
ASA Classification
I Healthy patient not undergoing elective surgery
II Patient with mild, controlled, and non-disabling systemic
disease
III Patient with severe but not disabling, systemic disease
IV Patient with severe and disabling systemic disease, which
also constitutes a constant threat to life and cannot always
be corrected through surgery
V Terminal or dying patient, whose life expectancy is not
expected to exceed 24 hours with or without surgical
treatment
VI Patient declared brain-dead, treated with support
measures to remove organs for transplantation
Although there is no general consensus as to its indica-
tion (7), pulse oximetry monitoring is recommended for all
high-risk patients who are going to undergo an endoscopic
procedure, regardless of whether they will receive sedation
or not (17,25). In patients with known heart disease elec-
trocardiographic monitoring is also recommended (11,26).
There are discordant results regarding the benefit of admi-
nistering supplemental oxygen to reduce the risk of CRC
in sedated patients undergoing endoscopic procedures (6),
results that could be extrapolated to non-sedated patients.
Asthma
Patients with bronchial asthma have a number of struc-
tural changes derived from chronic inflammation of the
airway, which causes greater resistance to air flow, along
with greater sensitivity and bronchial reactivity to external
stimuli (27). Certain chemical and mechanical stimuli, such
as the passage of the endoscope through the oropharynx or
the passage of secretions into the airway, activate the nerve
receptors distributed throughout the airway, triggering an
exacerbated bronchoconstriction reflex response in these
patients, which is mediated by the PSNS (28). It is estimated
Table 4. STOP-BANG Questionnaire
Snoring
Tiredness
Observed
Blood pressure
Body mass index (BMI)
Age
Neck
Gender
Risk of obstructive sleep apnea syndrome: low (answered yes in 0-2 questions), intermediate (answered yes in 3-4 questions), high (answered yes in 5-8 questions).
J. A. Vázquez Rodríguez et al.
that the risk of bronchospasm in the perioperative period of
asthmatic patients ranges from 0.17 % to 4.2 %, the main
risk factors being the proximity of an asthma crisis to the
time of procedure, poor clinical control of the disease, and
use of sedative drugs (29-31).
Optimal disease control is necessary to reduce the risk of
bronchospasm during EGD. It has been observed that the
use of β2-agonists before the procedure can decrease the
bronchoconstriction reflex with oropharyngeal manipula-
tion (32), and thus treatment with β2-agonists and corticos-
teroids in high-risk patients is recommended (29,32).
In these patients, it is necessary to question them about
recent respiratory infections, triggers, and degree of cli-
nical-functional control of the disease due to their impli-
cations for the occurrence of complications during the
procedure (29).
Chronic obstructive pulmonary disease (COPD)
Several studies have shown that patients with COPD expe-
rience episodes of desaturation and arrhythmia more fre-
quently during EGD without sedation than patients without
a history of respiratory disease (9,12,13,17). In addition to
the partial obstruction of the airway during EGD, and the
passage of secretions, it is thought that an alteration in the
ventilation/perfusion relationship may contribute to this
condition (17).
Patients with respiratory conditions and baseline saturation
below 95 % at the time of EGD have a higher risk of CRC
during the procedure (17), so it may be prudent to defer the
exploration in these cases.
Similar to asthmatic patients, recent infectious exacerba-
tions, as well as the degree of clinical-functional control
of the disease, are worth noting, and it is thus recommen-
ded that the treatment of the underlying disease be opti-
mized before performing the procedure to reduce the risk
of adverse events during DE.
Arrhythmias
Heart rhythm disturbances during DE are more frequent in
patients with ischemic heart disease or valvular heart disea-
se as compared to non-cardiac subjects (9,22,33,34), and as
Do you snore loudly?
Do you often feel tired, fatigued, or sleepy during daytime?
Has anyone observed you stop breathing during your sleep?
Do you have or are being treated for high blood pressure?
Body mass index over 35 kg/m2?
Age over 50 years old?
Neck circumference > 40 cm?
Male?
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 Cardiorespiratory complications of digestive endoscopy not related to sedation
previously mentioned, in those with COPD. Sinus tachycar-
dia and ventricular extrasystoles are the main arrhythmias
detected, usually without clinical significance when they
are self-limited and have no hemodynamic repercussion
(6,9,10).
Ischemic cardiomyopathy
In patients with ischemic cardiomyopathy (IC), changes in
the ST segment that may be present in patients with IC
during ED are especially relevant, since they are conside-
red as clinically significant for myocardial ischemia. Clas-
sically, it was thought that this ischemia was secondary
to hypoxemia, when the development of electrocardio-
graphic abnormalities coincided with desaturation episo-
des (22,33). However, some studies have questioned the
existence of a significant correlation between ischemia
and hypoxemia, suggesting that ischemia is secondary
to an increase in myocardial oxygen demand as a result
of increased cardiac workload during DE, similar to what
happens during a stress test (11,12,33,35). In most cases
these electrical changes do not have any clinical correlates
(34,35).
There is currently no consensus as to the optimal waiting
time required to safely perform an endoscopic procedure
in patients with recent acute coronary syndrome (ACS). In
scheduled endoscopic examinations it may be prudent to
defer the procedure a few months after the ischemic event,
a strategy that is not feasible in urgent cases. Tseng et al.
observed that patients with stable IC who had an urgent
EGD procedure for upper gastrointestinal bleeding (UGIB)
at least 60 days after an ischemic event had a higher inci-
dence and frequency of ventricular arrhythmias than the
healthy control group, also observing that in these patients
more frequent electrical changes may be seen in the elec-
trocardiogram (ST depression) without development of
angina or infarction during or after the procedure (34).
Spier et al. reported an inversely proportional relationship
between DE complications and proximity to an ischemic
event: among 135 patients, the only ones who developed
complications were those in whom the EGD had been per-
formed on the same day as the ACS, and no complications
were recorded in those who had an EGD at least 24 hours
after an ACS (36). A recent systematic review by Canadian
authors established the use of sedative drugs during the
endoscopic procedure, in addition to the temporal rela-
tionship between the ischemic event and DE, as a risk factor
for the development of cardiorespiratory complications in
these patients (26). In this review, the risk of cardiovascular
complications related to DE is estimated at 9.1 % after an
ACS, with the risk of death attributed to DE being 3.7 % of
total complications (26).
In patients with a recent ACS, an optimal anticoagulant
and antiplatelet therapy is recommended, together with
the use of proton pump inhibitors (PPIs), to attempt to
reduce the risk of bleeding and thus reduce the chances of
an emergency EGD procedure, which in turn might trigger
other complications (26). In cases where EGD is unavoi-
dable, it may be useful to use agents such as hemostatic
powders (Hemospray®), which allow rapid hemostasis, to
reduce endoscopic time and thus decrease the likelihood
of CRC (26).
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205
CONCLUSIONS
DE is considered to be a safe procedure with few contra-
indications. However, even in the absence of comorbidi-
ties or external factors such as the use of sedatives, the
body’s own physiological response to the different stimuli
derived from the procedure can trigger cardiorespiratory
adverse events. These are generally mild and self-limited;
however, sometimes they may have serious consequences,
especially in risk groups. The autonomic nervous system is
the main system involved in said response. Patients with
asthma and/or COPD have a higher risk of hypoxemia and
bronchospasm during the endoscopic procedure when
compared to the general population. Likewise, patients with
a history of cardiac arrhythmias or ischemic heart disease
have an increased risk of arrhythmia and myocardial ische-
mia during DE. In these patients it is essential to take pre-
cautions before, during, and after the procedure in order to
reduce adverse events and to allow taking quick, effective
action should these develop.
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