Noninvasive positive airway pressure for hypoxemia prevention during sedated gastrointestinal endoscopy in adults with obesity: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Adults with obesity undergoing gastrointestinal endoscopy under sedation are at increased risk of hypoxemia. We evaluated nasal continuous positive airway pressure (nCPAP) and noninvasive positive pressure ventilation (NIPPV) versus conventional oxygen therapy in this population. METHODS: We searched six databases from inception through May 2026 for randomized controlled trials evaluating nCPAP or NIPPV in adults with obesity undergoing gastrointestinal endoscopy. The review followed PRISMA guidelines and was registered in PROSPERO (CRD420261391143). The primary outcome was oxygen desaturation, defined as SpO2 <90% or ≤90% according to study definitions. Rescue airway maneuvers were secondary. Random-effects meta-analysis, trial sequential analysis, and GRADE were performed. RESULTS: Four RCTs comprising 457 participants were included. Positive airway pressure strategies reduced oxygen desaturation (RR 0.27; 95% CI 0.14-0.53; p<0.01; I2=0%), with moderate-certainty evidence. Rescue airway maneuvers were also reduced (RR 0.45; 95% CI 0.23-0.89; p=0.03; I2=46.5%); however, certainty was very low, and the prediction interval included no effect. Trial sequential analysis crossed the monitoring boundaries for benefit for both outcomes. Oxygen-delivery protocols differed across trials, and effective FiO2 was not directly measured. CONCLUSIONS: NCPAP or NIPPV may reduce oxygen desaturation during sedated gastrointestinal endoscopy in adults with obesity. The effect on rescue airway maneuvers remains uncertain. Larger trials using standardized oxygen-delivery and airway-rescue protocols are warranted.