Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

Abstract

Background Prone positioning (PP) improves oxygenation and respiratory mechanics and is associated with lower mortality in patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite this, some patients develop refractory hypoxemia and hypercapnia requiring venovenous extracorporeal membrane oxygenation (VV ECMO) support and are usually cared for in supine position. The physiologic and outcome benefits of routine PP of patients during VV ECMO remains unclear. Hence, we conducted the systematic review and meta-analysis to evaluate the outcome benefits of PP for patients with ARDS being treated with VV ECMO. Methods After registration with PROSPERO (CRD42020199723), MEDLINE, EMBASE, Scopus and Cochrane databases were searched for relevant studies that reported PP in more than 10 adult patients supported with VV ECMO from origin to 1 March 2021. Studies were reviewed for quality using appropriate Joanna Briggs Institute (JBI) checklists, and certainty of evidence was assessed using the GRADE approach. The random-effects model (DerSimonian and Laird) was used. The primary outcome of interest was cumulative survival. Secondary outcomes were intensive care unit length of stay (ICU LOS) and ECMO duration. Changes in arterial blood gas (ABG) values, ventilator mechanics and complication rates were also studied. Results Of 812 potentially relevant publications, 12 studies (640 patients) met our inclusion criteria. Due to overlapping study populations, 11 studies were included in the final meta-analysis. Cumulative survival in patients that underwent PP was 57% (95% CI 41.9–71.4, high certainty). Patients that underwent PP had longer ICU LOS (+ 14.5 days, 95% CI 3.4–25.7, p = 0.01) and ECMO duration (+ 9.6 days, 95% CI 5.5–13.7, p < 0.0001). After PP, patients had significantly higher PaO2/FiO2 ratio, lower PaCO2 and reduced ventilator driving pressure, and no major complications were reported. Conclusions PP during VV ECMO appears safe with a cumulative survival of 57% and may result in longer ECMO runs and ICU LOS. However, evidence from appropriately designed randomized trials is needed prior to widespread adoption of PP on VV ECMO.

Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

“…A recent systematic review related to PP in ECMO patients has been published [ 35 ]. The cumulative survival (pooling survival proportions from the longest postdischarge timepoint reported) in patients with PP was 57% [ 35 ].…”

“…A recent systematic review related to PP in ECMO patients has been published [ 35 ]. The cumulative survival (pooling survival proportions from the longest postdischarge timepoint reported) in patients with PP was 57% [ 35 ]. The cumulative survival among patients who were submitted to PP compared to those without PP was nonsignificant [ 35 ].…”

“…The cumulative survival (pooling survival proportions from the longest postdischarge timepoint reported) in patients with PP was 57% [ 35 ]. The cumulative survival among patients who were submitted to PP compared to those without PP was nonsignificant [ 35 ]. However, this latter meta-analysis [ 35 ] included only 7 studies, whereas 13 were included in the present study.…”

Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a pooled individual patient data analysis

“…Recently, the findings of the available studies on the use of PP during ECMO were pooled in in a systematic review and meta-analysis [ 23 ] that showed a non-significant trend towards decreased mortality in patients who underwent PP during ECMO. However, this meta-analysis by Poon et al (which also included 4 out of 5 studies included in our analysis) was performed on aggregate data (i.e.…”

Prone positioning in acute respiratory distress syndrome during venovenous extracorporeal membrane oxygenation

“…We read with respect the recent study by Dr. Poon [ 1 ], which investigated the potential benefit of prone positioning (PP) during venovenous extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS). Total of 11 studies were included and the pooled result showed a non-significant increasing trend of survival rate in patients receiving PP during ECMO (RR 1.2, 95% CI 0.9–1.5).…”