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Meta-Analysis
. 2022 Mar;48(3):270-280.
doi: 10.1007/s00134-021-06604-x. Epub 2022 Jan 17.

Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

Laurent Papazian  1   2 , Matthieu Schmidt  3 , David Hajage  4 , Alain Combes  3 , Matthieu Petit  3 , Guillaume Lebreton  5   6 , Jonathan Rilinger  7   8 , Marco Giani  9 , Camille Le Breton  10   11 , Thibault Duburcq  12 , Mathieu Jozwiak  13   14 , Tobias Wengenmayer  7   8 , Damien Roux  10   11 , Rachael Parke  15   16 , Anderson Loundou  17 , Christophe Guervilly  18   19 , Laurent Boyer  17
Affiliations
Meta-Analysis

Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

Laurent Papazian et al. Intensive Care Med. 2022 Mar.

Abstract

Purpose: Previous studies support the potential efficacy of venovenous extracorporeal membrane oxygenation (vvECMO) for improving survival in severe acute respiratory distress syndrome (ARDS) cases. Prone positioning (PP) has been shown to improve the outcomes of moderate-to-severe ARDS patients. Few studies and no randomized controlled trials have evaluated the effect of PP performed in ECMO patients.

Methods: We performed a systematic review and meta-analysis examining the effect of prone positioning for ARDS patients receiving vvECMO on survival. All authors were contacted to obtain complementary information not mentioned in the original articles. The main objective was to compare 28-day survival in vvECMO patients with PP to vvECMO patients without PP (controls).

Results: Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria. PP was associated with a significant improvement in 28-day survival (503 survivors among 681 patients in the PP group [74%; 95% CI 71-77] vs. 450 survivors among 770 patients in the control group [58%, 95% CI 55-62]; RR 1.31 [95% CI 1.21-1.41]; I2 22% [95% CI 0-62%]; P < 0.0001). Survival was also improved in terms of other endpoints (60-day survival, 90-day survival, ICU survival, and hospital survival). In contrast, the duration of mechanical ventilation was increased in vvECMO patients with PP (mean difference 11.4 days [95% CI 9.2-13.5]; 0.64 [95% CI 0.50-0.78]; I2 8%; P < 0.0001).

Conclusion: According to this meta-analysis, survival was improved when prone positioning was used in ARDS patients receiving vvECMO. The impact of this combination on survival should be investigated in prospective randomized controlled trials.

Keywords: ARDS; ECMO; Meta-analysis; Mortality; Prone positioning.

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Conflict of interest statement

LP received consultancy fees from Air Liquide MS, Faron and MSD. MS received consultancy fees from Getinge, Xenios FMC and Drager. DH has no conflicts of interest. AC received grants and personal fees from Maquet, Xenios and Baxter. MP has no conflicts of interest. GL reports lecture fees from Livanova and Abiomed. JR has no conflicts of interest. MG has no conflicts of interest. CLB has no conflicts of interest. TD has no conflicts of interest. TW received consulting fees from Abbott Medical, Boehringer Ingelheim, AstraZeneca, Bayer, Abiomed and Novartis. DR has no conflicts of interest. MJ has no conflicts of interest. RP has no conflicts of interest. AL has no conflicts of interest. CG received consultancy fees from Xenios FMC. LB received consultancy fees from Lundbeck and Janssen.

Figures

Fig. 1
Fig. 1
Flow diagram of study selection
Fig. 2
Fig. 2
A Survival at day 28. B Survival at day 28 according to the ARDS aetiology
Fig. 3
Fig. 3
Hospital survival
Fig. 4
Fig. 4
Hospital survival for the four studies using matching
See this image and copyright information in PMC

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