Prone Positioning During Extracorporeal Membrane Oxygenation in Patients With Severe ARDS

Abstract

ImportanceProne positioning may improve outcomes in patients with severe acute respiratory distress syndrome (ARDS), but it is unknown whether prone positioning improves clinical outcomes among patients with ARDS who are undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO) compared with supine positioning.ObjectiveTo test whether prone positioning vs supine positioning decreases the time to successful ECMO weaning in patients with severe ARDS supported by VV-ECMO.Design, Setting, and ParticipantsRandomized clinical trial of patients with severe ARDS undergoing VV-ECMO for less than 48 hours at 14 intensive care units (ICUs) in France between March 3, 2021, and December 7, 2021.InterventionsPatients were randomized 1:1 to prone positioning (at least 4 sessions of 16 hours) (n = 86) or to supine positioning (n = 84).Main Outcomes and MeasuresThe primary outcome was time to successful ECMO weaning within 60 days following randomization. Secondary outcomes included ECMO and mechanical ventilation–free days, ICU and hospital length of stay, skin pressure injury, serious adverse events, and all-cause mortality at 90-day follow-up.ResultsAmong 170 randomized patients (median age, 51 [IQR, 43-59] years; n = 60 women [35%]), median respiratory system compliance was 15.0 (IQR, 10.7-20.6) mL/cm H2O; 159 patients (94%) had COVID-19–related ARDS; and 164 (96%) were in prone position before ECMO initiation. Within 60 days of enrollment, 38 of 86 patients (44%) had successful ECMO weaning in the prone ECMO group compared with 37 of 84 (44%) in the supine ECMO group (risk difference, 0.1% [95% CI, −14.9% to 15.2%]; subdistribution hazard ratio, 1.11 [95% CI, 0.71-1.75]; P = .64). Within 90 days, no significant difference was observed in ECMO duration (28 vs 32 days; difference, −4.9 [95% CI, −11.2 to 1.5] days; P = .13), ICU length of stay, or 90-day mortality (51% vs 48%; risk difference, 2.4% [95% CI, −13.9% to 18.6%]; P = .62). No serious adverse events were reported during the prone position procedure.Conclusions and RelevanceAmong patients with severe ARDS supported by VV-ECMO, prone positioning compared with supine positioning did not significantly reduce time to successful weaning of ECMO.Trial RegistrationClinicalTrials.gov Identifier: NCT04607551

Outcomes of Severe ARDS COVID-19 Patients Denied for Venovenous ECMO Support: A Prospective Observational Comparative Study

“…For patients indicated for VV-ECMO, the 90-day survival rate of 62.1% of our cohort is consistent with large studies and registries [15,16], and it is slightly higher than the rate reported in a recent randomized controlled study assessing the continuation of the prone position during VV-ECMO [17].…”

Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a prospective multicenter randomized controlled study

“…Therefore, the relationship between PP and ECMO duration requires further investigation. Recent study on this aspect found that prone positioning did not significantly reduce time to successful weaning of ECMO ( 21 ). Our subgroup analysis was consistent with it.…”

S1PR3 inhibition protects against LPS-induced ARDS by inhibiting NF-κB and improving mitochondrial oxidative phosphorylation

“…The prognosis of patients with ARDS has improved in recent years due to increased awareness and effective supportive therapy [ 1 , 2 ]. However, ARDS-related mortality remains unacceptably high, as shown by a recent study in which the 60-day mortality was up to 44.1% among those with severe ARDS [ 3 ]. Currently, effective treatments for ARDS are still lacking, and ARDS remains one of the major public health burdens worldwide.…”