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

Hongjie Tong; Feiyan Pan; Xiaoling Zhang; Shengwei Jia; Rishik Vashisht; Kun Chen; Qianqian Wang

doi:10.21037/jtd-23-1808

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

J Thorac Dis. 2024 Feb 29;16(2):1368-1377. doi: 10.21037/jtd-23-1808. Epub 2024 Jan 15.

Authors

Hongjie Tong^#¹, Feiyan Pan^#¹, Xiaoling Zhang¹, Shengwei Jia², Rishik Vashisht³, Kun Chen¹, Qianqian Wang⁴

Affiliations

¹ Department of Intensive Care Medicine, Affiliated Jinhua Hospital Zhejiang University School of Medicine, Jinhua, China.
² Department of Intensive Care Unit, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China.
³ Sentara Pulmonary Critical Care and Sleep Specialists, Sentara Norfolk General Hospital, Norfolk, Virginia, USA.
⁴ Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing, China.

^# Contributed equally.

Abstract

Background: Current data supporting the use of prone positioning (PP) during venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with acute respiratory distress syndrome (ARDS) are limited. This prospective randomized controlled study aimed to determine whether PP implemented within 24 hours of ECMO can improve survival in these patients.

Methods: From June 2021 to July 2023, 97 adult patients receiving VV-ECMO for ARDS in three centers were enrolled and 1:1 randomized into PP (n=49) and control groups (n=48). Patients in the PP group receiving prone positioning, while the control group were maintained in the supine position. The primary outcome was 30-day survival, and secondary outcomes included in-hospital survival and other clinical outcomes.

Results: All 97 patients were included for analysis. Patient characteristics did not significantly differ between the two groups. The median duration of PP was 81 hours, and the median number of PP sessions was 5 times. PP improved oxygenation and ventilator parameters. The incidence of complications during PP was low, with pressure sores being the most frequent (10.2%). The 30-day survival was significantly higher in the PP group (67.3% vs. 45.8%; P=0.033), as was in-hospital survival (61.2% vs. 39.6%; P=0.033). In the PP group, the successful ECMO weaning rate was significantly higher (77.5% vs. 50.0%; P=0.005), and the duration of ECMO support was significantly shorter {10 [8-11] vs. 10 [8-14] days; P=0.038}. However, in subgroup analysis of COVID patients the 30-day survival, in-hospital survival, successful ECMO weaning rate and the duration of ECMO support did not differ between the groups. The duration of mechanical ventilation, length of intensive care unit stay, and length of hospital stay did not significantly differ between the groups.

Conclusions: When initiated within 24 hours of ECMO, PP can improve 30-day survival in patients with ARDS receiving VV-ECMO. In addition, it may improve the successful ECMO weaning rate and reduce the duration of ECMO support. However, considering the limitations, more strictly designed, large sample prospective randomized controlled trials are proposed.

Trial registration: Chinese Clinical Trial Registry ChiCTR2300075326.

Keywords: Prone positioning (PP); acute respiratory distress syndrome (ARDS); adult; extracorporeal membrane oxygenation (ECMO).