Prone Positioning During Extracorporeal Membrane Oxygenation in Patients With Severe ARDS
Authors: Schmidt Matthieu , Hajage David , Lebreton Guillaume , Dres Martin , Guervilly Christophe , Richard Jean Christophe , Sonneville Romain , Winiszewski Hadrien , Muller Gregoire , Beduneau Gaëtan , Mercier Emmanuelle , Roze Hadrien , Lesouhaitier Mathieu , Terzi Nicolas , Thille Arnaud W. , Laurent Isaura , Kimmoun Antoine , Combes Alain ,   PRONECMO Investigators, the REVA Network, and the International ECMO Network (ECMONet), Luyt Charles Edouard , Hekimian Guillaume , Brechot Nicolas , Chommeloux Juliette , Pineton de Chambrun Marc , Saura Ouriel , Levy David , Lefevre Lucie , Assouline Benjamin , Bahroum Petra , Gautier Melchior , Leprince Pascal , Juvin Charles , Demondion Pierre , Bergue Elodie , Danial Pichoy , Al-kabani Hamed , Bounader Karl , Schoell Thibaut , D'Allesandro Cosimo , Bureau Côme , Le Marec Julien , Mayaux Julien , Decavèle Maxens , Demoule Alexandre , Deleris Robin , Nemlaghi Safaa , Lecronier Marie , Capellier Gilles , Piton Gael , Belon Francois , Vieille Thibault , Lafay Valentin , Manfait Camille , Tapponnier Romain , Belin Nicolas , Gacouin Arnaud , Tadié Jean-Marc , Papazian Laurent , Hraiech Sami , Forel Jean-Marie , Roch Antoine , Adda Mélanie , Daviet Florence , Gragueb-Chatti Ines , Textoris Laura , Timsit Jean-François , Bouadma Lila , de Montmollin Etienne , Lamara Fariza , Deiler Véronique , Para Marylou , Nataf Patrick , Zmihi Sylia , Wicky Paul Henri , Patrier Juliette , Jaquet Pierre , Levy Bruno , Perez Pierre , Thivilier Carine , Mattei Mathieu , Haddadi Clément , Kozutski Matthieu , Maureira Pablo , Yonis Hodane , Mezidi Medhi , Chauvelot Louis , Danjou William , Dhelft Francois , Bitker Laurent , Bettinger Clotilde , Bernon Pauline , Jolly Grégoire , Carpentier Dorothée , Nay Mai-Anh , Boulain Thierry , Kamel Toukif , Barbier Francois , Bretagnol Anne , Mathonnet Armelle , Desgrouas Maxime , Skarzynski Marie , Repusseau Benjamin , Sigaud Florian , Rigault Guillaume , Galerneau Louis-Marie , Schwebel Carole , Candille Clara , Dartevel Anaïs , Bougnaud Joanna , Turbil Emanuele , Ehrmann Stephan , Garot Denis , Salmon Charlotte , Le Pape Sylvain , Arrivé Francois 
Published: December 2023

Importance

Prone 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.

Objective

To 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 Participants

Randomized 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.

Interventions

Patients 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 Measures

The 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.

Results

Among 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 Relevance

Among 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 Registration

ClinicalTrials.gov Identifier: NCT04607551