Efficacy and safety of prone positioning in patients undergoing extracorporeal membrane oxygenation (ECMO): A systematic review and meta-analysis.

Summary

Across 17 studies of ARDS patients on VV-ECMO, prone positioning improved 30-day and in-hospital survival and enhanced oxygenation/PaCO2, but did not improve 60- or 90-day survival, ICU survival, or ECMO weaning. Earlier and more frequent proning shortened mechanical ventilation and ICU stays, with greater early survival benefit in non-COVID cohorts.

Key Findings

• ECMO+prone positioning improved 30-day and in-hospital survival.
• No significant benefit for 60-day, 90-day, ICU survival, or ECMO weaning rates.
• Significant improvements in oxygenation and reductions in PaCO2 with ECMO+proning.
• Earlier and more frequent proning sessions shortened mechanical ventilation and ICU length of stay; non-COVID cohorts derived greater early survival benefit.

Clinical Implications

Consider early and repeated prone positioning during VV-ECMO to improve oxygenation and early survival, especially in non-COVID ARDS, while counseling that long-term survival benefits remain uncertain.

Limitations

• Predominantly observational studies with risk of residual confounding
• Heterogeneity in proning protocols, timing, and patient populations
• Potential publication bias and lack of randomized trials

Future Directions

Prospective randomized trials to quantify causal effects of proning during ECMO, optimal timing/frequency, and identification of subgroups most likely to benefit.