ECMO vs. early prone positioning: What offers best patient outcomes
By Tara Psencik, BSN RN
Acute Respiratory Distress Syndrome (ARDS) remains one of the most challenging conditions in critical care, with high mortality and complex management decisions. Two of the most discussed interventions in severe ARDS are early prone positioning and extracorporeal membrane oxygenation (ECMO). But which one truly leads to better outcomes?
Prone Positioning: A Proven, Accessible Strategy
The PROSEVA trial in 2013 was a landmark moment for prone ventilation. In patients with severe ARDS, placing patients in the prone position for at least 16 hours a day reduced 28-day mortality from 32.8% to just 16%—a 41% relative mortality reduction. Subsequent meta-analyses have confirmed this effect, particularly when combined with lung-protective ventilation strategies.
Key Benefits:
- Significant mortality reduction in moderate-to-severe ARDS
- Low-cost, widely accessible
- Fewer complications compared to more invasive therapies
Best Use: Initiate early (within 24–48 hours of ARDS diagnosis) and maintain for ≥12–16 hours daily.
ECMO: A High-Stakes Rescue Option
ECMO offers a way to oxygenate the blood externally when the lungs are failing. Studies like CESAR and EOLIA suggest a 25% relative risk reduction in 90-day mortality in selected patients. But ECMO comes with caveats: it’s invasive, resource-intensive, and carries risks such as bleeding, infection, and neurologic complications.
When It Helps:
- Refractory hypoxemia despite optimal ventilation and proning
- Younger patients with fewer comorbidities
- Use in specialized, high-volume ECMO centers improves outcomes
ECMO vs. Proning: Head-to-Head
Direct comparisons are rare, but recent studies offer some insights:
Metric | Prone Ventilation | ECMO |
Mortality Benefit | 26–41% relative reduction | 25% relative reduction (in selected patients) |
Cost/Risk | Low cost, low complication risk | High cost, significant risk profile |
Evidence Base | Strong RCT data (PROSEVA) | Moderate RCT/observational data (CESAR, EOLIA) |
Ideal Use | First-line in moderate-severe ARDS | Rescue for refractory cases |
What About Combining Both?
Emerging research suggests that combining ECMO with prone positioning may enhance early survival.
- A 2021 retrospective single-center registry (158 ECMO patients, 38 proned): no difference in weaning success or hospital survival overall. However, early prone initiation (<17h) was linked to significantly lower hospital mortality (≈82% vs. 33%)
- Post-ECMO proning study (2024 prospective observational): Patients proned before EMCO initiation who continued proning afterward showed improved ECMO weaning and survival.
However, trials like PRONECMO (2024) found no difference in 90-day mortality between patients on ECMO with or without proning. While the combined approach is safe, it may lead to longer ICU stays without added survival benefit—at least based on current data.
Final Takeaway
Consider starting with early prone positioning ( ≥12–16 h/day + lung-protective ventilation) for moderate-to-severe ARDS —it’s proven, effective, and relatively simple. Studies suggest escalating to ECMO if severe hypoxemia persists or patient deteriorates despite optimal mechanical ventilation and prone strategy. In selected patients, ECMO can be lifesaving, but it’s not a replacement for foundational ARDS care.
At Turn Medical, we’re committed to supporting critical care teams with the tools they need to safely and effectively prone their patients. The Pronova-O2 Prone Therapy System is designed with features that facilitate both prone positioning and the integration of ECMO as part of a comprehensive treatment plan.
Contact us today for expert assistance with your proning protocols and to be connected with ECMO centers that have successfully implemented Pronova-O2—achieving positive patient outcomes.
855-ASK-TURN or info@turnmedical.com
References:
Combes, A., Hajage, D., Capellier, G., Demoule, A., Lavoué, S., Guervilly, C., Daix, T., Beduneau, G., Luyt, C.-E., Bouadma, L., Schmidt, M., Mercat, A., Brochard, L., Richard, J.-C., & EOLIA Trial Group. (2018). Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. New England Journal of Medicine, 378(21), 1965–1975. https://doi.org/10.1056/NEJMoa1800385
Peek, G. J., Mugford, M., Tiruvoipati, R., Wilson, A., Allen, E., Thalanany, M. M., Hibbert, C. L., Truesdale, A., Clemens, F., Cooper, N., Firmin, R. K., & Elbourne, D. (2009). Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet, 374(9698), 1351–1363. https://doi.org/10.1016/S0140-6736(09)61069-2
Guérin, C., Reignier, J., Richard, J.-C., Beuret, P., Gacouin, A., Boulain, T., Mercier, E., Badet, M., Mercat, A., Baudin, O., Clavel, M., Chatellier, D., Jaber, S., Rosselli, S., Mancebo, J., Sirodot, M., Hilbert, G., Bengler, C., Richecoeur, J., … Ayzac, L. (2013). Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine, 368(23), 2159–2168. https://doi.org/10.1056/NEJMoa1214103
Sud, S., Friedrich, J. O., Taccone, P., Polli, F., Adhikari, N. K. J., Latini, R., Pesenti, A., & Ferguson, N. D. (2010). Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Medicine, 36, 585–599. https://doi.org/10.1007/s00134-009-1748-1
Munshi, L., Walkey, A., Goligher, E., Pham, T., Uleryk, E., Fan, E., & Brodie, D. (2021). Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Annals of the American Thoracic Society, 18(12), 1970–1980. https://doi.org/10.1513/AnnalsATS.202104-440OC
Giani, M., Martucci, G., Madotto, F., Fumagalli, J., Bonifazi, M., Cattaneo, S., Busana, M., Spadaro, S., Chiumello, D., & Grasselli, G. (2022). Prone positioning during venovenous extracorporeal membrane oxygenation for acute
respiratory distress syndrome: A systematic review and meta-analysis. Critical Care, 26, 6. https://doi.org/10.1186/s13054-021-03897-1
Coppola, S., Ferrari, F., & Galletti, A. (2022). Prone positioning in patients on veno-venous ECMO support for ARDS: A systematic review and meta-analysis. Critical Care and Resuscitation, 24(1), 12–22. https://pubmed.ncbi.nlm.nih.gov/35180060/
Richard, J.-C. M., Bréchot, N., Hraiech, S., Schmidt, M., Lebreton, G., Combes, A., Brodie, D., & Guérin, C. (2024). Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: The PRONECMO randomized clinical trial. JAMA, 331(11), 999–1008. https://doi.org/10.1001/jama.2024.1606
