1. Objectives of the Talk

  • Review prone positioning inARDS
  • Explore theimpact of COVID-19 on proning practices
  • Discussprone positioning during ECMO support:
    • Is it safe?
    • How to perform it?
  • Highlightfuture research directions

2. Background

  • First described byCharles Bryan (1974): repositioning improves oxygenation by expanding dependent lung regions and reducing V/Q mismatch.
  • Early devices (1976 “rotating bed”) suggested PO₂ improvement and better secretion clearance.

3. Physiological Benefits

Lung Performance

  • Improvesventilation-perfusion (V/Q) matching
  • Expandsdependent lung regions
  • Reducesalveolar compression (less abdominal pressure on diaphragm)

Hemodynamics

  • ReducesRV preload and afterload
  • Improvesright ventricular function in severe ARDS

4. Evidence in ARDS (Pre-COVID)

  • Early studies (2001–2010): inconsistent mortality benefit
    • Short proning durations, higher tidal volumes (~10 mL/kg)
  • PROSEVA trial (2013):
    • Severe ARDS, early proning (<24 hrs)
    • 17 hrs/day prone, protective ventilation (TV 6 mL/kg)
    • Showedclear mortality benefit

Key Concept:

Effectiveness depends on timing, duration, and protective ventilation strategy.

5. Awake Prone Positioning During COVID-19

  • Positive studies:
    • Awake proning withHFNC or NIV → improved oxygenation, reduced intubation rates
  • Negative studies:
    • Large multicenter and RCTs showedno reduction in mortality and only temporary delay of intubation

6. Prone Positioning During ECMO

  • Why question arose:If proning helps ARDS, could it help during ECMO?
  • COVID-19 data:
    • International consortium + French multicenter cohorts:
      • Proning on ECMO reduced mortality(49% vs 60%)
      • Especially effective when startedearly (<1 week of ECMO) and continued ~17 hrs/day
    • Randomized trial (2023):
      • No significant difference in weaning/survival
      • Limitations: small sample size, single-center dominance → not generalizable

Conclusion: Evidence remains mixed.

7. Safety & Practical Considerations

  • Generally safeif:
    • Properpatient selection
    • Multidisciplinary trained team
    • Strict cannula monitoring
  • Complications:
    • Most common:minor bleeding at cannula site
    • Rare:cannula dislodgement
  • Requiresprotocols & checklists
    • Manual proning vs ceiling lifts
    • Continuous observation of circuit integrity

8. Debate: Proning vs Awake ECMO

  • Proning on ECMO:
    • Improves gas exchange, shown survival benefit in some studies
    • Often requiresdeep sedation → risk of delirium, weakness, cognitive impairment
  • Awake ECMO strategy:
    • Extubate early, mobilize patient, minimize sedation
    • Reduces long-term complications but may miss proning benefit
  • Key Balance:
    • Lung restvs patient mobilization
    • Avoiding sedation harms vs preventing severe hypoxemia

9. Key Takeaways

  1. ARDS + Proning: Proven mortality benefit when early, prolonged, and combined with lung-protective ventilation.
  2. COVID-19 awake proning: Mixed evidence; may help oxygenation, but no clear survival advantage.
  3. Proning during ECMO:
    • Retrospective data suggest benefit
    • RCTs inconclusive → more large, multicenter studies needed
  4. Safety: Feasible with trained team, structured protocol, and cannula monitoring.
  5. Future direction: Balanceprone positioning vs awake ECMO strategies; tailor approach with imaging, gas exchange trials, and patient-specific assessment.
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