High-Flow Nasal Cannula and Capnography for Sedation Safety in Pancreatobiliary Endoscopy

Pancreatobiliary endoscopic procedures, including endoscopic retrograde cholangiopancreatography and interventional endoscopic ultrasound–guided drainage, increasingly involve prolonged and technically demanding interventions requiring deep sedation. These procedures are frequently performed in elderly patients with multiple comorbidities, in whom respiratory adverse events remain a major cause of procedure-related morbidity. Conventional low-flow oxygen supplementation and pulse oximetry alone are often insufficient to prevent or promptly detect sedation-related ventilatory failure. High-flow nasal cannula has emerged as an effective oxygenation strategy, providing stable delivery of high inspired oxygen concentrations and reducing hypoxemia during endoscopic procedures. However, improved oxygenation may mask early ventilatory compromise. Capnography complements oxygen therapy by enabling real-time monitoring of ventilation and early detection of hypoventilation or apnea before oxygen desaturation occurs. This review summarizes current evidence on high-flow nasal cannula and capnography in pancreatobiliary endoscopy, discusses their respective physiological roles and clinical limitations, and highlights the rationale for a risk-based, integrated approach. Combining optimized oxygen delivery with early ventilation monitoring may enhance sedation safety, particularly in high-risk patients undergoing complex pancreatobiliary interventions.