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Observational Study
. 2022 Feb 1;50(2):275-285.
doi: 10.1097/CCM.0000000000005296.

Beneficial Effect of Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019

Akram M Zaaqoq  1 , Adrian G Barnett  2 , Matthew J Griffee  3 , Graeme MacLaren  4 , Jeffrey P Jacobs  5 , Silver Heinsar  6 , Jacky Y Suen  6 , Gianluigi Li Bassi  6   7 , John F Fraser  6   8 , Heidi J Dalton  9 , Giles J Peek  5 ; COVID-19 Critical Care Consortium (COVID Critical)
Affiliations
Observational Study

Beneficial Effect of Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019

Akram M Zaaqoq et al. Crit Care Med. .

Abstract

Objectives: The study investigated the impact of prone positioning during venovenous extracorporeal membrane oxygenation support for coronavirus disease 2019 acute respiratory failure on the patient outcome.

Design: An observational study of venovenous extracorporeal membrane oxygenation patients. We used a multistate survival model to compare the outcomes of patients treated with or without prone positioning during extracorporeal membrane oxygenation, which incorporates the dynamic nature of prone positioning and adjusts for potential confounders.

Setting: Seventy-two international institutions participating in the Coronavirus Disease 2019 Critical Care Consortium international registry.

Patients: Coronavirus disease 2019 patients who were supported by venovenous extracorporeal membrane oxygenation during the study period.

Intervention: None.

Measurements and main results: There were 232 coronavirus disease 2019 patients at 72 participating institutions who were supported with venovenous extracorporeal membrane oxygenation during the study period from February 16, 2020, to October 31, 2020. Proning was used in 176 patients (76%) before initiation of extracorporeal membrane oxygenation and in 67 patients (29%) during extracorporeal membrane oxygenation. Survival to hospital discharge was 33% in the extracorporeal membrane oxygenation prone group versus 22% in the extracorporeal membrane oxygenation supine group. Prone positioning during extracorporeal membrane oxygenation support was associated with reduced mortality (hazard ratio, 0.31; 95% CI, 0.14-0.68).

Conclusions: Our study highlights that prone positioning during venovenous extracorporeal membrane oxygenation support for refractory coronavirus disease 2019-related acute respiratory distress syndrome is associated with reduced mortality. Given the observational nature of the study, a randomized controlled trial of prone positioning on venovenous extracorporeal membrane oxygenation is needed to confirm these findings.

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Conflict of interest statement

Dr. Jacobs received funding from SpecialtyCare and the American Academy of Dermatology. Dr. Heinsar received funding via PhD scholarship from the University of Queensland. Dr. Bassi’s institution received funding from Fisher & Paykel. Dr. Dalton received funding from Innovative Extracorporeal Membrane Oxygenation (ECMO) Concepts; she disclosed the off-label product use of ECMO equipment. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
Cumulative probabilities over time for the four states. The plots show the cumulative probability over time of moving between states. A, The probabilities for patients in the “ECMO and prone” state. B, The probabilities for patients in the “ECMO and supine” state. There is a steady accumulation of deaths in patients in the supine group (solid line [B]), although this slows after around 40 d. The movement of patients from the supine to the prone group greatly reduces after around 12 d (dashed gray line [B]). ECMO = extracorporeal membrane oxygenation.
Figure 2.
Figure 2.
Estimated risk of death and discharge by time in prone position. There is gradual decrease in the probability of death associated with the duration of prone position.
See this image and copyright information in PMC

Comment in

References

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