Complications of Prone Positioning During Extracorporeal Membrane Oxygenation for Respiratory Failure: A Systematic Review

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is often used in patients with severe respiratory failure to improve oxygenation and survival. ECMO gives the lungs an opportunity to rest and recover. The addition of prone positioning therapy used concurrently with ECMO can further aid in optimizing alveolar recruitment and reducing ventilator-induced lung injury, ultimately resulting in fewer ICU admission days and improved overall survival. The objective of this review is to perform a systematic analysis of the complications reported with prone positioning and ECMO in the adult population and to briefly report on the patient outcomes in the studies.

METHODS: PubMed, MEDLINE, Cochrane Library, and CINAHL were searched from January 1, 1960 to September 14, 2014. Studies were included if they examined both extracorporeal membrane oxygenation and prone positioning simultaneously for the treatment of respiratory failure in the adult population.

RESULTS: Seven studies fit the study inclusion criteria (1 prospective cohort study, 3 retrospective cohort studies, and 3 case series). All of the studies in this review reported no occurrence of ECMO cannula dislodgment, and 2 studies reported cannula site bleeding. Chest tube dislodgment and airway dislodgment did not occur in any of the studies included. Bleeding from the chest tube site was reported in 13.5% of prone positioning maneuvers in 1 study, and the rest of the studies reported no evidence of chest tube site bleeding. Of the 2 studies that reported hemodynamic instability during the prone positioning maneuvers, very few adverse hemodynamic episodes were reported. The authors who reported adverse effects stated that the episodes were quickly and successfully reversible.

CONCLUSIONS: This review highlights the limited complications documented during prone positioning and ECMO. More studies are needed to assess the clinical efficacy of the addition of prone positioning therapy to ECMO for patients in severe respiratory failure.