Should You Consider Prone Positioning Before ECMO?

Aaron B. Holley, MD


June 13, 2018

Taking a New Position

Last fall I admitted a 41-year-old patient with hypoxic respiratory failure to the intensive care unit. He rapidly declined, and I consulted the extracorporeal membrane oxygenation (ECMO) service at my hospital. They considered him a reasonable candidate and agreed to cannulate him and start support.

One of our younger staff members suggested prone positioning first, citing better efficacy data as his rationale. Good points, but I dismissed him outright. Prone positioning might recruit lung and improve gas exchange over time, but in this case we had run out of time. In my opinion, only ECMO could save him.

This past winter I admitted a 71-year-old patient with influenza complicated by cavitary, bacterial pneumonia. When he deteriorated, ECMO was considered. Because he was older and with additional comorbid disease, the ECMO team viewed him as a poor candidate and advised prone positioning.

Again, I scoffed. I did not think we were out of time, I just felt that prone positioning would not reverse his profound hypercapnia. I was wrong. He stabilized, his gas exchange improved, and he never required ECMO.

A Closer Look at the Evidence

A recently published perspective[1] makes the case for using prone positioning before starting ECMO. The authors reviewed the literature and found 17 eligible studies with data on 672 patients in whom ECMO was initiated. Of note, they only included patients started on veno-venous ECMO and excluded those requiring cardiac support.

Only 208 patients (31%) were placed in the prone position prior to being cannulated. The authors were unable to determine why prone positioning rates were so low. They propose lack of familiarity, inadequate training, concern about complications, or lack of belief in its impact.

My own reluctance was due to each of these factors, at least in part. I believe in prone positioning and I am confident in the data from randomized trials.[2,3] I also believe that the physiology is sound.[4] However, because my hospital is an ECMO center, it is actually easier (and faster) to start ECMO than it is to get a rotational bed. Nursing and staff are more comfortable with ECMO. Last, although I understand and believe in prone positioning, I underestimated the potential improvements that could result.

I am not ready to state unequivocally that all patients should receive a prone positioning trial prior to ECMO. However, the data from this perspective[1] suggest that prone positioning is significantly underutilized. The authors are correct: Prone positioning is proven, comparatively inexpensive, and, in my anecdotal experience, will provide stabilization without ECMO in some cases.

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