Prone positioning does not shorten time to successful ECMO weaning in ARDS

Key takeaways:

• Among patients with acute respiratory distress syndrome, 44.2% in prone position and 44% in supine position weaned off of ECMO by day 60.
• Mortality at 90 days was comparable between groups.

Time to successful weaning off of extracorporeal membrane oxygenation was similar for prone and supine positioning among patients with severe acute respiratory distress syndrome, according to results published in JAMA.

“Among patients with severe ARDS supported by venovenous extracorporeal membrane oxygenation (VV-ECMO), prone positioning during ECMO did not significantly reduce time to successful weaning of ECMO,” Matthieu Schmidt, MD, PhD, assistant professor of intensive care medicine at University of Paris, and colleagues wrote.

In a randomized clinical trial conducted in France, Schmidt and colleagues assessed 170 patients (median age, 51 years; 35% women) from 14 ICUs with severe ARDS on VV-ECMO for less than 2 days to compare time to successful weaning between prone positioning (n = 86) and supine positioning (n = 84) by day 60.

Most patients in the total cohort had COVID-19-related ARDS (94%) and were placed in prone position prior to receiving ECMO (96%).

Within the prone positioning group, 69 (80%) patients underwent a minimum of four sessions, each lasting 16 hours, whereas the remaining patients discontinued the intervention prior to reaching this minimum, according to researchers.

Between the two groups, researchers found a similar number of patients who successfully weaned off of ECMO 60 days after randomization (prone, 44.2% vs. supine, 44%), for a risk difference of only 0.1% (95% CI, –14.9% to 15.2%).

Failure to wean off ECMO and death before weaning also did not significantly differ when evaluating prone positioning vs. supine positioning, according to researchers.

In addition to weaning, researchers evaluated several secondary outcomes at day 90. Similar to the findings above, prone- and supine-positioned patients had comparable lengths of ECMO and mechanical ventilation, time spent in the hospital and ICU, and 90-day mortality rates (51% vs. 48%).

Further, both groups had similar percentages of patients who experienced a ventilator-associated pneumonia episode within 60 days (prone, 85% vs. supine, 89%).

Patients in the prone positioning group did not experience any serious adverse events such as unintentional ECMO decannulation, nonscheduled extubation or severe hemoptysis, according to researchers.

Notably, more patients in supine position suffered from cardiac arrest than patients in prone position (11 patients vs. 3 patients; RR = 0.27; 95% CI, 0.08-0.92). Both groups had comparable percentages of patients with bleeding events.

When discussing the results, Schmidt and colleagues wrote that because most of the patients in this study had COVID-19-related ARDS, they are not sure if the same results would be found among those with non-COVID-19-related ARDS.

“Prior international cohorts suggested that patients with COVID-19 rescued by ECMO had longer ECMO runs and ICU lengths of stay than that reported in the EOLIA [ECMO to Rescue Lung Injury in Severe ARDS] trial or other large, retrospective series of ECMO for non-COVID-19-related ARDS,” Schmidt and colleagues wrote. “Thus, it remains uncertain whether the current trial findings are generalizable to patients with severe non-COVID-19-related ARDS.”