TOPLINE:
In contrast to previous observational studies, a randomized trial showed no advantage to prone positioning over supine positioning in weaning patients with severe acute respiratory distress syndrome (ARDS) from extracorporeal membrane oxygenation (ECMO).
METHODOLOGY:
- The researchers randomized 170 adults with severe ARDS who underwent venovenous ECMO; the median age of patients was 51 years, 35% were women, and the most common cause of ARDS was COVID-19 pneumonia (94%).
- The primary outcome was successful ECMO weaning within 60 days, defined as survival without ECMO or a lung transplant for 30 days after discontinuing ECMO.
- Failure to wean from ECMO was defined as the need for a second ECMO run, a lung transplant, or death within 30 days of ECMO discontinuation.
TAKEAWAY:
- At 60 days, 44% of patients in each group achieved successful ECMO weaning; rates of ECMO weaning failure and death were similar between the groups.
- Secondary outcomes including death at 90 days, duration of ECMO and mechanical ventilation, and ICU and hospital lengths of stay were similar between prone and supine groups.
- Cardiac arrest rates were significantly higher in the supine ECMO group than in the prone group (13.1% vs 3.5%; P = .05); bleeding events that led to packed red blood cell transfusion and hemorrhagic stroke were similar in supine and prone groups (38.1% vs 27.9% and 1.2% vs 2.3%, respectively).
- No significant differences in treatment effects emerged in subgroup analyses by body mass index, respiratory system compliance at randomization, or treatment at a high ECMO volume center.
IN PRACTICE:
"The neutral result also raises the prospect that the etiology or severity of ARDS and subsequent biology may exhibit differential responses to prone positioning," the researchers wrote.
SOURCE:
The lead author on the study was Matthieu Schmidt, MD, of the Hôpital de la Pitié-Salpêtrière,Paris, France. The study was published online in JAMA on December 1, 2023.
LIMITATIONS:
The small sample size and inclusion only of patients at a single, experienced center may limit generalizability of the results, and the unblinded study design may have introduced bias.
DISCLOSURES:
The study was supported by a grant from the French Ministry of Health. Dr Schmidt disclosed lecture fees from Getinge, Dräger, Baxter, and Fresenius Medical Care.
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