Physiologic Wins Without Survival Gain? Prone Positioning in VV-ECMO-Treated ARDS

Öz

Background: Prone positioning (PP) is a well-established strategy to improve oxygenation in Acute Respiratory Distress Syndrome (ARDS) patients; however, its role during Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) remains uncertain. Objective: To evaluate the impact of PP on Intensive Care Unit (ICU) survival and respiratory parameters in patients with ARDS supported by VV-ECMO. Methods: This retrospective observational study included 100 adult patients who underwent VV-ECMO for respiratory failure between 2015 and 2024. Patients were divided into two groups: hose who received prone positioning during ECMO (≥16 hours) and those who remained supine. Clinical characteristics, ventilatory parameters, and outcomes were compared. Results: Forty-five patients (45%) underwent PP during ECMO. Although ICU survival was higher in the prone group (53.7% vs. 46.3%), the difference was not statistically significant (p=0.246). However, PP was associated with significant improvements in driving pressure, mechanical power, compliance, and gas exchange indices in the post-prone period. Conclusion: While PP during VV-ECMO did not significantly improve survival, it contributed to favorable physiological changes, supporting its use as an adjunctive therapy in ARDS management under ECMO. Keywords: Prone Positioning, ECMO, Respiratory Mechanics, ARDS, Lung Protective Ventilation

Anahtar Kelimeler

• Prone Positioning
• ECMO
• Respiratory Mechanics
• ARDS
• Lung Protective Ventilation

Sağkalıma Yansımayan Fizyolojik Kazanımlar: VV-ECMO ile Tedavi Edilen ARDS Hastalarında Prone Pozisyonunun Etkisi

Öz

Giriş: Prone Pozisyon (PP), Akut Respiratuar Distres Sendromu (ARDS) hastalarında oksijenasyonu iyileştirmek için yaygın olarak kullanılan bir yöntemdir; ancak Venovenöz Ekstrakorporeal Membran Oksijenizasyon (VV-ECMO) tedavisi sırasında PP, etkinliği belirsizliğini korumaktadır. Amaç: çalışmamızda VV-ECMO desteği altındaki ARDS hastalarında PP'nin yoğun bakım mortalitesi ve solunum parametreleri üzerindeki etkisini değerlendirmek amaçlanmaktadır. Yöntemler: Bu retrospektif gözlemsel çalışmaya, 2015-2024 yılları arasında solunum yetmezliği nedeniyle VV-ECMO uygulanan 100 erişkin hasta dahil edildi. Hastalar, ECMO sırasında en az 16 saat prone pozisyonu uygulananlar ve supin pozisyonda kalanlar olmak üzere iki gruba ayrıldı. Klinik özellikler, ventilatör parametreleri ve yoğun bakım mortalite açısından karşılaştırıldı. Bulgular: Hastaların %45’ine (n=45) ECMO süresince PP uygulandı. Prone grubunda yoğun bakım sağkalımı daha yüksek olmakla birlikte (53.7% vs. 46.3%), istatistiksel olarak anlamlı fark bulunamadı (p=0.246). Ancak PP sonrası dönemde drive basıncı, mekanik güç, kompliyans ve oksijenizasyon parametrelerinde anlamlı iyileşmeler gözlendi. Sonuç: VV-ECMO sırasında prone pozisyonu sağkalımı anlamlı şekilde artırmasa da, olumlu fizyolojik değişikliklere katkıda bulunarak ECMO destekli ARDS yönetiminde tamamlayıcı bir tedavi seçeneği olarak düşünülmektedir. Anahtar Kelimeler: Prone Pozisyon, EKMO, Solunum Mekanikleri, ARDS, Akciğer Koruyucu Ventilasyon

Anahtar Kelimeler

• Prone Pozisyon
• EKMO
• Solunum Mekanikleri
• ARDS
• Akciğer Koruyucu Ventilasyon

Kaynakça

1. Shrestha DB, Sedhai YR, Budhathoki P, et al. Extracorporeal Membrane Oxygenation (ECMO) Dependent Acute Respiratory Distress Syndrome (ARDS): A Systematic Review and Meta-Analysis. Cureus. 2022;14(6):e25696. Crossref
2. Rehder KJ, Alibrahim OS. Mechanical Ventilation during ECMO: Best Practices. Respir Care. 2023;68(6):838-845. Crossref
3. Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of ARDS. Intensive Care Med. 2019;45(6):792-808.
4. Sud S, Friedrich JO, Adhikari NK, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ. 2014;186(10):E381-E390. Crossref
5. Wang YX, Zhong M, Dong MH, et al. Prone positioning improves ventilation-perfusion matching assessed by electrical impedance tomography in patients with ARDS: a prospective physiological study. Crit Care. 2022;26(1):154. Crossref
6. Kallet RH. A Comprehensive Review of Prone Position in ARDS. Respir Care. 2015;60(11):1660-1687. Crossref
7. Berg RMG, Hartmann JP, Iepsen UW, et al. Therapeutic benefits of proning to improve pulmonary gas exchange in severe respiratory failure: focus on fundamentals of physiology. Exp Physiol. 2022;107(7):759-770. Crossref
8. Culbreth RE, Goodfellow LT. Complications of Prone Positioning During Extracorporeal Membrane Oxygenation for Respiratory Failure: A Systematic Review. Respir Care. 2016;61(2):249-254. Crossref

9. Tong H, Pan F, Zhang X, et al. 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;16(2):1368-1377. Crossref
10. Chen Z, Li M, Gu S, et al. Effect of prone position in patients with acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation: a retrospective cohort study. BMC Pulm Med. 2022;22(1):234. Crossref
11. Poon WH, Ramanathan K, Ling RR, et al. Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care. 2021;25(1):292. Crossref
12. Wang R, Wang W, Tang X, et al. Association between ventilation-perfusion matching improvement during initial prone positioning and ICU mortality in patients with moderate to severe ARDS: a prospective two-center study. Ann Intensive Care. 2025;15(1):69. Crossref
13. Schmidt M, Hajage D, Lebreton G, et al; PRONECMO Investigators, the REVA Network, and the International ECMO Network (ECMONet). Prone Positioning During Extracorporeal Membrane Oxygenation in Patients With Severe ARDS: The PRONECMO Randomized Clinical Trial. JAMA. 2023;330(24):2343-2353. Erratum in: JAMA. 2024;331(5):446. Crossref
14. van Minnen O, Jolink FEJ, van den Bergh WM, Droogh JM, Oude Lansink-Hartgring A; Dutch ECLS Study Group. International Survey on Mechanical Ventilation During Extracorporeal Membrane Oxygenation. ASAIO J. 2024;70(4):300-304. Crossref
15. Liang H, Deng Q, Ye W, et al. Prone position ventilation-induced oxygenation improvement as a valuable predictor of survival in patients with acute respiratory distress syndrome: a retrospective observational study. BMC Pulm Med. 2024;24:575. Crossref
16. Aoyama H, Pettenuzzo T, Aoyama K, Pinto R, Englesakis M, Fan E. Association of Driving Pressure With Mortality Among Ventilated Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(2):300-306. Crossref
17. Giani M, Martucci G, Madotto F, et al. Prone Positioning during Venovenous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome. A Multicenter Cohort Study and Propensity-matched Analysis. Ann Am Thorac Soc. 2021;18(3):495-501. Crossref
18. Zaaqoq AM, Barnett AG, Heinsar S, et al; COVID-19 Critical Care Consortium (COVID Critical). Prone position during venovenous extracorporeal membrane oxygenation: survival analysis needed for a time-dependent intervention. Crit Care. 2022;26(1):39. Crossref
19. Chen PH, Lee CH, Yen WT, et al. Efficacy and safety of prone positioning in patients undergoing extracorporeal membrane oxygenation (ECMO): A systematic review and meta-analysis. J Clin Anesth. 2025;103:111786. Crossref
20. Pettenuzzo T, Balzani E, Sella N, et al. Prone positioning during veno-venous extracorporeal membrane oxygenation: a systematic review and meta-analysis. Intensive Care Med. 2025;51(5):930-941. Crossref