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To assess the efficacy of an ECG-based method called thoracic impedance pneumography to reduce hypoxic events in endoscopy. This was a single center, 1:1 randomized controlled trial. The trial was conducted during the placement of percutaneous endoscopic gastrostomy (PEG). 173 patients who underwent PEG placement were enrolled in the present trial. Indication was oncological in most patients (89%). 58% of patients were ASA class II and 42% of patients ASA class III. Patients were randomized in the standard monitoring group (SM) with pulse oximetry and automatic blood pressure measurement or in the intervention group with additional thoracic impedance pneumography (TIM). Sedation was performed with propofol by gastroenterologists or trained nurses. Hypoxic episodes defined as SpO 2 < 90% for >15 s were the primary endpoint. Secondary endpoints were minimal SpO 2 , apnea >10s/>30s and incurred costs. Additional use of thoracic impedance pneumography reduced hypoxic episodes (TIM: 31% vs SM: 49%; p = 0.016; OR 0.47; NNT 5.6) and elevated minimal SpO 2 per procedure (TIM: 90.0% ± 8.9; SM: 84.0% ± 17.6; p = 0.007) significantly. Apnea events >10s and > 30s were significantly more often detected in TIM (43%; 7%) compared to SM (1%; 0%; p < 0.001; p = 0.014) resulting in a time advantage of 17 s before the occurrence of hypoxic events. As a result, adjustments of oxygen flow were significantly more often necessary in SM than in TIM (p = 0.034) and assisted ventilation was less often needed in TIM (2%) compared with SM (9%; p = 0.053). Calculated costs for the additional use of thoracic impedance pneumography were 0.13$ (0.12 €/0.11 £) per procedure. Additional thoracic impedance pneumography reduced the quantity and extent of hypoxic events with less need of assisted ventilation. Supplemental costs per procedure were negligible. Key words: thoracic impedance pneumography, capnography, sedation, monitoring, gastrointestinal endoscopy, percutaneous endoscopic gastrostomy. • What is known? • Sedation related complications are common especially in high risk endoscopic procedures such as PEG placement • Standard monitoring consists of pulse oximetry, blood pressure monitoring and ECG in known severe heart disease. • Endoscopic guidelines highlight the value of ventilatory monitoring by capnography to prevent apnea and hypoxic events • Thoracic impedance pneumography is another method to monitor ventilation and detect apnea events depending on a three‑lead ECG • What is new here? • Additional thoracic impedance monitoring reduced hypoxic events quantitatively and qualitatively. • The method is simple and commonly available in gastrointestinal endoscopy. • Countermeasures (e.g. bag-mask ventilation) to prevent apnea and hypoxia were less frequently necessary • Costs of thoracic impedance pneumography are negligible with only 0,13$ (0,04€/0,035£) per procedure. [ABSTRACT FROM AUTHOR]