Early application of prone positioning did not help patients with severe acute respiratory distress syndrome (ARDS) — mostly from COVID — get off venovenous extracorporeal membrane oxygenation (VV-ECMO) any faster compared to supine positioning, a randomized trial found.
Among ARDS patients receiving ECMO, an identical 44% of patients were successfully weaned off ECMO after 60 days whether they were placed in sessions of prone positioning or simply kept supine (P=0.64), reported Matthieu Schmidt, MD, of the Hôpital de la Pitié-Salpêtrière in Paris, and colleagues.
Within 90 days, there was no significant difference seen in ECMO duration between prone and supine groups (28 vs 32 days, P=0.13). Also no different were 90-day mortality rates between positions (51% vs 48%, P=0.62), according to the French PRONECMO study published in JAMAopens in a new tab or window.
“Despite promising findings in observational studies, prone positioning of patients undergoing ECMO failed to reduce ECMO duration or mortality in this randomized trial,” Schmidt and coauthors concluded.
Prone positioning has been shown to reduce mortality in ARDSopens in a new tab or window, and promotes “better overall ventilation/perfusion matching through a more homogeneous distribution of gas-tissue ratios along the dependent-nondependent axis in addition to decreased levels of lung stress and strain,” the investigators explained in their introduction.
But whether the benefit extended to ARDS patients on VV-ECMO was unclear. One recent meta-analysis of 13 observational studiesopens in a new tab or window had found prone positioning during ECMO for ARDS — COVID-19 or not — to be associated with a significant improvement in ventilator-free days and intensive care unit (ICU) survival, Schmidt’s group noted.
Prone positioning is strongly recommended in current clinical practice guidelines, noted Ricardo Teijeiro-Paradis, MD, and Niall Ferguson, MD, MSc, both of the University of Toronto, in an accompanying editorialopens in a new tab or window.
“Based on these results, routine prone positioning during VV-ECMO does not facilitate earlier liberation from ECMO or improve outcomes. This suggests that on average, prone positioning does not facilitate further lung protection than that already provided with an ultraprotective ventilation strategy facilitated by VV-ECMO,” Teijeiro-Paradis and Ferguson wrote.
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