Pettenuzzo Tommaso, Balzani Eleonora, Sella Nicolò, Giani Marco, Bassi Mara, Fincati Valentina, Cescon Rossella, Pacchiarini Giorgia, Pandolfo Giovanna, Ceccato Roberta, Grønlykke Lars, Staudacher Dawid L, Nesseler Nicolas, Raasveld Senta Jorinde, Carron Michele, Pistollato Elisa, Mormando Giulia, Zarantonello Francesco, De Cassai Alessandro, Boscolo Annalisa, Rezoagli Emanuele, Foti Giuseppe, Navalesi Paolo
Institute of Anesthesia and Intensive Care, University Hospital of Padua, Padua, Italy.
Department of Surgical Sciences, University of Turin, Turin, Italy.
Intensive Care Med. 2025 Apr 29. doi: 10.1007/s00134-025-07877-2.
The evidence supporting the benefit on clinical outcomes of prone positioning during veno-venous extracorporeal membrane oxygenation (V-V ECMO) for acute hypoxemic respiratory failure remains inconclusive. We aimed to assess the association of prone positioning, compared to no prone positioning, with 28-day mortality and other clinical outcomes in different patient subgroups.
A systematic review and meta-analysis of randomized and non-randomized controlled trials (RCTs) using a random-effects model was conducted. An electronic database search up to September 1st, 2024 was performed (PROSPERO CRD42024517602). The RoB 2 and ROBINS-I tools were used for risk of bias assessments.
We analyzed two RCTs and 20 non-RCTs (3,465 patients). Compared to no prone positioning, the use of prone positioning was associated with lower 28-day (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42-0.98, p = 0.040, I = 66%, low certainty of evidence [CoE]) and hospital mortality (OR 0.67, 95% CI 0.54-0.83, p < 0.001, I = 39%, low CoE), despite fewer 28-day ventilator-free days and longer ECMO duration. Younger age (p = 0.005), a higher sequential organ failure assessment (SOFA) score (p = 0.022), non-Covid-19 etiology (p = 0.003), and lower rates of prone positioning before cannulation (p = 0.049) were associated with a greater benefit from prone positioning.
In this analysis, among patients supported with V-V ECMO for acute hypoxemic respiratory failure, we observed improved 28-day and hospital mortality in those who received prone positioning, compared to those who did not. However, these findings do not imply causation. Further research is needed to clarify the role of prone positioning in this population.
关于静脉-静脉体外膜肺氧合（V-V ECMO）治疗急性低氧性呼吸衰竭时俯卧位对临床结局有益的证据仍不明确。我们旨在评估与非俯卧位相比，俯卧位与不同患者亚组28天死亡率及其他临床结局之间的关联。
采用随机效应模型对随机对照试验（RCT）和非随机对照试验进行系统评价和荟萃分析。截至2024年9月1日进行了电子数据库检索（PROSPERO CRD42024517602）。使用RoB 2和ROBINS-I工具进行偏倚风险评估。
我们分析了2项RCT和20项非RCT（共3465例患者）。与非俯卧位相比，采用俯卧位与较低的28天死亡率（比值比[OR]0.64，95%置信区间[CI]0.42 - 0.98，p = 0.040，I = 66%，证据确定性低[CoE]）和医院死亡率（OR 0.67，95% CI 0.54 - 0.83，p < 0.001，I = 39%，低CoE）相关，尽管28天无呼吸机天数较少且ECMO持续时间较长。年龄较小（p = 0.005）、序贯器官衰竭评估（SOFA）评分较高（p = 0.022）、非新冠病毒-19病因（p = 0.003）以及插管前俯卧位使用率较低（p = 0.049）与俯卧位带来的更大益处相关。
在本分析中，对于接受V-V ECMO治疗急性低氧性呼吸衰竭的患者，我们观察到与未接受俯卧位的患者相比，接受俯卧位的患者28天和医院死亡率有所改善。然而，这些发现并不意味着存在因果关系。需要进一步研究以阐明俯卧位在该人群中的作用。
