Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome

Garcia, Bruno; Cousin, Nicolas; Bourel, Claire; Jourdain, M.; Poissy, Julien; Duburcq, Thibault; Boddaert, Pauline; Durand, Arthur; Kalioubie, Ahmed El; Girardie, Patrick; Houard, Marion; Ledoux, G.; Moreau, Anne; Nilès, Christopher; Nseir, Saad; Onimus, Thierry; Toussaint, Aurélia; Preau, Sébastien; Robriquet, Laurent; Rouzé, Anahita; Simonnet, Arthur; Six, Sophie; Caplan, Morgan; Goutay, Julien; Jaillette, Emmanuelle; Parmentier-Decrucq, Erika; Favory, Raphaël; Mathieu, Daniel; Degouy, Guillaume; Moussa, Mouhamed Djahoum

doi:10.1186/s13054-020-03162-4

Cited by 55 publications

(78 citation statements)

References 6 publications

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“…The high mortality rate even among the responders in this study might be explained by the higher severity of patients and the use of iEPO as the last resort. Likewise, Garcia et al ( 16 ) reported the survival rate of 14.3% in their cohort with veno-venous-ECMO for COVID-19 patients that underwent PP, whereas Shelhamer et al ( 17 ) reported mortality of 77.4% in the PP group and 83.9% in the control group that did not undergo PP. The authors explained that the high mortality was contributed by the severe acuity of patients receiving those treatments (PP or ECMO) as rescue therapy.…”

Section: Discussionmentioning

confidence: 99%

Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia

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Augustynovich

et al. 2020

Critical Care Explorations

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Section: Discussionmentioning

confidence: 99%

Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia

Fink

Augustynovich

et al. 2020

Critical Care Explorations

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“…Patients who undergo PP during ECMO have been shown to have significantly prolonged duration of ECMO support as well as ICU LOS [ 18 , 19 , 21 , 24 ] It is likely that the patients subjected to PP during ECMO were sicker, which explains the need for the intervention as well as the longer duration of ECMO. Given the immortal time bias associated with interventions like ECMO, it is also plausible that sicker patients could have died earlier and thus did not undergo prone positioning, thereby accounting for the higher mortality.…”

Section: Discussionmentioning

confidence: 99%

Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

et al. 2021

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Background Prone positioning (PP) improves oxygenation and respiratory mechanics and is associated with lower mortality in patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite this, some patients develop refractory hypoxemia and hypercapnia requiring venovenous extracorporeal membrane oxygenation (VV ECMO) support and are usually cared for in supine position. The physiologic and outcome benefits of routine PP of patients during VV ECMO remains unclear. Hence, we conducted the systematic review and meta-analysis to evaluate the outcome benefits of PP for patients with ARDS being treated with VV ECMO. Methods After registration with PROSPERO (CRD42020199723), MEDLINE, EMBASE, Scopus and Cochrane databases were searched for relevant studies that reported PP in more than 10 adult patients supported with VV ECMO from origin to 1 March 2021. Studies were reviewed for quality using appropriate Joanna Briggs Institute (JBI) checklists, and certainty of evidence was assessed using the GRADE approach. The random-effects model (DerSimonian and Laird) was used. The primary outcome of interest was cumulative survival. Secondary outcomes were intensive care unit length of stay (ICU LOS) and ECMO duration. Changes in arterial blood gas (ABG) values, ventilator mechanics and complication rates were also studied. Results Of 812 potentially relevant publications, 12 studies (640 patients) met our inclusion criteria. Due to overlapping study populations, 11 studies were included in the final meta-analysis. Cumulative survival in patients that underwent PP was 57% (95% CI 41.9–71.4, high certainty). Patients that underwent PP had longer ICU LOS (+ 14.5 days, 95% CI 3.4–25.7, p = 0.01) and ECMO duration (+ 9.6 days, 95% CI 5.5–13.7, p < 0.0001). After PP, patients had significantly higher PaO2/FiO2 ratio, lower PaCO2 and reduced ventilator driving pressure, and no major complications were reported. Conclusions PP during VV ECMO appears safe with a cumulative survival of 57% and may result in longer ECMO runs and ICU LOS. However, evidence from appropriately designed randomized trials is needed prior to widespread adoption of PP on VV ECMO.

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“…A recent report about prone positioning in COVID-19 VV ECMO patients did not show improved survival, although it did improved oxygenation. 45 This study has some limitations. First, the decision to include only studies with at least 100 VV ECMO patients was arbitrary, and aimed at including only large studies.…”

Section: Discussionmentioning

confidence: 91%

Venovenous ECMO treatment, outcomes, and complications in adults according to large case series: A systematic review

et al. 2020

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Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) has gained popularity for the treatment of refractory respiratory failure during and after the 2009 influenza pandemic, and still represents a precious therapeutic resource for severe novel coronavirus 2019 infection. However, most of the published studies are small case series, and only two randomized trials exist in literature. Aim: Aim of this systematic review is to describe trends in VV ECMO treatment outcomes according to large studies only. Methods: We searched and included studies with more than 100 VV ECMO cases dated up to August 1st, 2019. Results: Thirty-three studies published in the period 2011–2019 met inclusion criteria, for a total of 12,860 patients (age 46.3 ± 17.4 years). ARDS was mainly by pneumonia, in 3126 (37%) cases; further 401(7%) patients had H1N1 Influenza A infection. Cannulation-related complications occurred in 502 (7%) cases. Weighted mean (95% confidence interval) of VV ECMO duration was 8.9 (8.7–9.1) days, and ICU stay was 23.6 (22.4–24.8) days. Mortality at the longest follow up available was 40%. Data collection in 70% of the studies had a duration of >5 years. Conclusion: This study reveals the characteristics of large case VV ECMO studies.

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Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome

Cited by 55 publications

References 6 publications

Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia

Effects of Inhaled Epoprostenol and Prone Positioning in Intubated Coronavirus Disease 2019 Patients With Refractory Hypoxemia

Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

Venovenous ECMO treatment, outcomes, and complications in adults according to large case series: A systematic review

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