title: Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and respiratory compliance.
abstract: BACKGROUND
  Data are sparse regarding the effects of prolonged prone positioning (PP) during VV-ECMO. Previous studies, using short sessions (<12 h), failed to find any effects on respiratory system compliance. In the present analysis, the effects of prolonged PP sessions (24 h) were retrospectively studied with regard to safety data, oxygenation and respiratory system compliance.
  
  
  METHODS
  Retrospective review of 17 consecutive patients who required both VV-ECMO and prone positioning. PP under VV-ECMO was considered when the patient presented at least one unsuccessful ECMO weaning attempt after day 7 or refractory hypoxemia combined or not with persistent high plateau pressure. PP sessions had a duration of 24 h with fixed ECMO and respiratory settings. PP was not performed in patients under vasopressor treatment and in cases of recent open chest cardiac surgery.
  
  
  RESULTS
  Despite optimized protective mechanical ventilation and other adjuvant treatment (i.e. PP, inhaled nitric oxide, recruitment maneuvers), 44 patients received VV-ECMO during the study period for refractory acute respiratory distress syndrome. Global survival rate was 66 %. Among the latter, 17 patients underwent PP during VV-ECMO for a total of 27 sessions. After 24 h in prone position, PaO2/FiO2 ratio significantly increased from 111 (84-128) to 173 (120-203) mmHg (p < 0.0001) while respiratory system compliance increased from 18 (12-36) to 32 (15-36) ml/cmH2O (p < 0.0001). Twenty-four hours after the return to supine position, tidal volume was increased from 3.0 (2.2-4.0) to 3.7 (2.8-5.0) ml/kg (p < 0.005). PaO2/FiO2 ratio increased by over 20 % in 14/14 sessions for late sessions (≥7 days) and in 7/13 sessions for early sessions (<7 days) (p = 0.01). Quantitative CT scan revealed a high percentage of non-aerated or poorly-aerated lung parenchyma [52 % (41-62)] in all patients. No correlation was found between CT scan data and respiratory parameter changes. Hemodynamics did not vary and side effects were rare (one membrane thrombosis and one drop in ECMO blood flow).
  
  
  CONCLUSIONS
  When used in combination with VV-ECMO, 24 h of prone positioning improves both oxygenation and respiratory system compliance. Moreover, our study confirms the absence of serious adverse events.
authors.affiliation: CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. akimmoun@gmail.com.|INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. akimmoun@gmail.com.|Université de Lorraine, 54000, Nancy, France. akimmoun@gmail.com.
authors.forename: Antoine
authors.initials: A
authors.lastname: Kimmoun
authors.affiliation: CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. sylvain.roche@bmx.com.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Roche
authors.affiliation: CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. c.bridey@chu-nancy.fr.
authors.forename: Céline
authors.initials: C
authors.lastname: Bridey
authors.affiliation: INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. f.vanhuyse@chu-nancy.fr.|Université de Lorraine, 54000, Nancy, France. f.vanhuyse@chu-nancy.fr.|CHU Nancy, Département de Chirugie Cardiaque Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. f.vanhuyse@chu-nancy.fr.
authors.forename: Fabrice
authors.initials: F
authors.lastname: Vanhuyse
authors.affiliation: INSERM, Centre d'Investigations Cliniques-9501 and CHU de Nancy, 54511, Vandoeuvre les Nancy, France. r.fay@chu-nancy.fr.
authors.forename: Renaud
authors.initials: R
authors.lastname: Fay
authors.affiliation: INSERM, Centre d'Investigations Cliniques-9501 and CHU de Nancy, 54511, Vandoeuvre les Nancy, France. n.girerd@chu-nancy.fr.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Girerd
authors.affiliation: Université de Lorraine, 54000, Nancy, France. d.mandry@chu-nancy.fr.|CHU Nancy, Département de Radiologie, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. d.mandry@chu-nancy.fr.
authors.forename: Damien
authors.initials: D
authors.lastname: Mandry
authors.affiliation: CHU Nancy, Service de Réanimation Médicale Brabois, Pole Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, 54511, Vandoeuvre les Nancy, France. b.levy@chu-nancy.fr.|INSERM U 1116, Groupe Choc, Equipe 2, Faculté de Médecine, 54511, Vandoeuvre les Nancy, France. b.levy@chu-nancy.fr.|Université de Lorraine, 54000, Nancy, France. b.levy@chu-nancy.fr.
authors.forename: Bruno
authors.initials: B
authors.lastname: Levy
keywords: ARDS; ECMO; Prone positioning