Ilyass Masad, Hamza Najout, Abderrahmane Elwali, Mustapha Bensghir
Journal: Medpeer Publisher
ISSN: 3066-2737
Volume: 3
Issue: 10
Date of Publication: 2026/10/08
Background: Sedation for upper gastrointestinal endoscopy in patients with severe obesity is challenging because reduced functional residual capacity, increased upper-airway collapsibility, frequent sleep-disordered breathing, and sedative-induced ventilatory depression can produce rapid hypoxemia. High-flow nasal oxygen (HFNO) and non-pharmacological adjuncts such as immersive virtual reality (VR) may complement careful titration of propofol. Case presentation: A 35-year-old woman with class III obesity (body mass index 46 kg/m²) and arterial hypertension treated with amlodipine was scheduled for preoperative esophagogastroduodenoscopy before sleeve gastrectomy. Routine laboratory investigations were unremarkable. Sedation was performed with propofol target-controlled infusion (TCI) using the Marsh model;. Immersive VR was used as a distraction/anxiolytic adjunct. Heated and humidified HFNO was delivered at 69 L/min, 37°C, with FiO₂ 0.50. The endoscopy was completed using this multimodal strategy.
Discussion: Patients with class III obesity have limited respiratory reserve and increased susceptibility to upper-airway obstruction during propofol sedation. The HFNO settings used in this case closely resemble those evaluated in the ODEPHI trial (70 L/min, FiO₂ 0.50), in which HFNO reduced SpO₂ ≤92% from 33.5% to 9.4%. A 2025 multicenter randomized trial in 984 patients with obesity reduced hypoxia from 21.2% to 2.0% with HFNO. Nevertheless, a 2026 randomized trial in obese patients undergoing gastroscopy showed that HFNO reduced desaturation while apnea remained frequent, emphasizing that improved oxygenation does not guarantee adequate ventilation. Conventional Marsh pharmacokinetics also have limitations at extremes of body weight; TCI targets should therefore be interpreted as a titration framework rather than an absolute pharmacodynamic endpoint. VR is promising for reducing anxiety and may reduce sedative exposure, but evidence remains heterogeneous and its respiratory-protective role is unproven.
Conclusion: Sedation for gastroscopy in class III obesity should be treated as a high-risk airway procedure. A multimodal bundle combining individualized propofol titration, proactive HFNO, enhanced respiratory surveillance, airway rescue readiness, and selected non-pharmacological adjuncts may improve procedural safety and patient experience.
class III obesity; gastrointestinal endoscopy; propofol; target-controlled infusion; high-flow nasal oxygen; virtual reality; procedural sedation; hypoxemia.
Download PDF