Efficacy of proning in acute respiratory distress syndrome on extracorporeal membrane oxygenation

Stephanie H Chang; Deane E Smith; Julius A Carillo; Philip M Sommer; Travis C Geraci; David Williams; Darien Paone; Ronald Goldenberg; Justin Chan; Zachary N Kon; Aubrey C Galloway; Nader Moazami

doi:10.1016/j.xjtc.2022.08.027

Efficacy of proning in acute respiratory distress syndrome on extracorporeal membrane oxygenation

JTCVS Tech. 2022 Dec:16:109-116. doi: 10.1016/j.xjtc.2022.08.027. Epub 2022 Sep 23.

Affiliations

¹ Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY.
² Department of Anesthesia, Perioperative Care, and Pain Medicine, New York University Langone Health, New York, NY.
³ Department of Medicine, New York University Langone Health, New York, NY.
⁴ Department of Cardiothoracic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY.

Abstract

Objectives: Proning patients with acute respiratory distress syndrome (ARDS) has been associated with increased survival, although few data exist evaluating the safety and feasibility of proning patients with ARDS on extracorporeal membrane oxygenation (ECMO).

Methods: A single-institution retrospective review of all patients with ARDS placed on ECMO between March 1 and May 31, 2020, was performed. All proning events were evaluated for complications, as well as change in compliance, sweep, oxygenation, and flow. The primary outcome of this study was the rate major morbidity associated with proning while on ECMO.

Results: In total, 30 patients were placed on ECMO for ARDS, with 12 patients (40%) proned while on ECMO. A total of 83 proning episodes occurred, with a median of 7 per patient (interquartile range, 3-9). No ECMO cannula-associated bleeding, cannula displacement, or endotracheal tune dislodgements occurred (0%). Oropharyngeal bleeding occurred twice (50%). Four patients were proned with chest tubes in place, and none had complications (0%). Lung compliance improved after proning in 70 events (84%), from a mean of 15.4 mL/mm Hg preproning to 20.6 mL/mm Hg postproning (P < .0001). Sweep requirement decreased in 36 events (43%). Oxygenation improved in 63 events (76%), from a mean partial pressure of oxygen of 86 preproning to 103 postproning (P < .0001). Mean ECMO flow was unchanged.

Conclusions: Proning in patients with ARDS on ECMO is safe with an associated improvement in lung mechanics. With careful planning and coordination, these data support the practice of appropriately proning patients with severe ARDS, even if they are on ECMO.

Keywords: ARDS, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; ECMO, extracorporeal membrane oxygenation; EMCO; IJ, internal jugular; IQR, interquartile range; NYULH, New York University Langone Health; P/F, ratio of arterial oxygen partial pressure to fractional inspired oxygen; PEEP, positive end-expiratory pressure; VV, venovenous; pCO2, partial pressure of arterial carbon dioxide; pO2, partial pressure of oxygen; proning.