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