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Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome


Infection due to severe acute respiratory coronavirus 2 (SARS-CoV-2) may lead to an atypical acute respiratory distress syndrome (ARDS) [1], requiring in the most severe cases veno-venous extracorporeal membrane oxygenation (VV-ECMO). The management of persistent severe hypoxemia under VV-ECMO requires a multi-step clinical approach including prone positioning (PP), which could improve oxygenation [2].


We performed a retrospective study of patients with SARS-CoV-2-induced ARDS submitted to PP during VV-ECMO. We aimed to describe mechanical ventilation parameters and gas exchanges before and after PP. We assess the safety of PP and compare patients with PP under ECMO (prone ECMO group) to those maintained in the supine position (supine ECMO group). Patients were treated in accordance with the recommendation guidelines on ARDS [3]. During VV-ECMO, PP was considered in case of severe hypoxemia (PaO2/FiO2 ratio below 80 mmHg) despite FDO2 and FiO2 both at 100% and in case of extensive lung consolidation (ECL) on chest imaging (> 50% of lung volume).


We enrolled 208 COVID-19 patients. Among the 125 patients with ARDS, 25 (20%) required VV-ECMO, and 14 (56%) were placed at least once in PP for a total of 24 procedures with a median duration of 16 (15–17) h. The delay from ECMO implantation therapy to PP was 1.5 days [1,2,3]. The resultant changes in ventilator/ECMO settings and blood gas analysis before and after PP are displayed in Table 1. The median PaO2/FiO2 ratio improvement after PP was 28% [2–36]. High responders (increase PaO2/FiO2 ratio > 20%) were 62.5%, moderate-responders (increase PaO2/FiO2 < 20%) were 16.7%, and non-responders (decrease PaO2/FiO2) were 20.8%. We did not observe any major safety concerns but only pressure sores after 6 procedures, three minor hemorrhages at the injection cannula, and three moderate drops in VV-ECMO flow requiring fluid resuscitation. Pre-ECMO characteristics, ventilator/ECMO settings, and outcomes are exposed in Table 2. Patients in the prone ECMO group were less likely to be weaned from ECMO, and 28-day mortality rate was significantly higher.

Table 1 The resultant changes in ventilator/ECMO settings and blood gas analysis before and after PP
Table 2 Pre-ECMO characteristics, ventilator/ECMO settings, and outcomes


We report that during VV-ECMO, PP improved oxygenation without a change in respiratory system compliance and PaCO2 at constant levels of minute ventilation and sweep gas flow. This does not suggest lung recruitment by PP but rather an optimization of ventilation and perfusion matching. Three explanations could be advanced for the mortality rate in the prone ECMO group (78.6%). First, prone ECMO patients may be more severe than supine ECMO patients. As described by Gattinoni et al., worsening patients progress from type 1 to type 2 (higher percentage of non-aerated tissue) [1], which is associated with a higher mortality rate [4]. Prone ECMO patients had much more consolidations, obviously because ECL was the main indication to be prone (n = 10/14). Furthermore, prone ECMO patients need a higher respiratory rate for a higher sweep gas flow suggesting that they may be exposed to a higher mechanical power, and they possibly had also a higher dead space. Second, postmortem biopsies, performed in 6 patients with ECL in the prone ECMO group, found a fibrin exudative presence both in the alveolar spaces and bronchioles followed by a fibroblastic phase [5] and raise the question of the use of corticosteroids (only one patient in the prone ECMO group). Third, as already described by Zeng et al. [6], more than half (8/11) of the patients died from septic shock and multiple organ failure, for which ECMO may be useless.


Prone positioning under VV-ECMO improves oxygenation in SARS-CoV-2-induced ARDS without compromising the safety of the patients. The high mortality rate in prone ECMO patients may be explained by the greater illness severity and the lack of an immunomodulatory therapy such as corticosteroids.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.



Acute respiratory distress syndrome


Intensive care unit


Prone positioning


Veno-venous extracorporeal membrane oxygenation


Severe acute respiratory syndrome coronavirus 2

FiO2 :

Fraction of inspired oxygen

PaO2 :

Arterial partial pressure of oxygen

FDO2 :

Fraction on oxygen delivered in the sweep gas


Extensive lung consolidation


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The authors are indebted to thank the whole members of the Lille Intensive Care COVID-19 Group and the entire nursing staff of the intensive care unit of the “Roger Salengro Hospital” of the “Centre Hospitalier Universitaire de Lille.”.

Lille Intensive Care COVID-19 group:

Pauline Boddaert1 (, Arthur Durand1 (, Ahmed El Kalioubie1 (, Patrick Girardie1 (, Marion Houard1 (, Geoffrey Ledoux1 (, Anne Sophie Moreau1 (, Christopher Niles1 (, Saad Nseir1 (, Thierry Onimus1 (, Aurelia Toussaint1 (, Sebastien Préau1 (, Laurent Robriquet1 (, Anahita Rouze1 (, Arthur Simonnet1 (, Sophie Six1 (, Morgan Caplan1 (, Julien Goutay1 (, Emmanuelle Jaillette1 (, Erika Parmentier-Decrucq1 (, Raphael Favory1 (, Daniel Mathieu1 (, Guillaume Degouy (, Mouhamed Moussa2 (Mouhamed.MOUSSA@CHRU-LILLE.FR)

1Pôle de Réanimation, CHU Lille, University of Lille, F-59000 Lille, France

2Service d’Anesthésie-Réanimation Cardio-Vasculaire, CHU Lille, University of Lille, F-59000 Lille, France


This study was supported by the French government through the Programme Investissement d’Avenir (I-SITE ULNE / ANR-16-IDEX-0004 ULNE) managed by the Agence Nationale de la Recherche ("PHYSIO COVID" and "PREDICT" projects)

Author information





B.G and T.D. conceived the study. B.G, C.B., and N.C. collected the data. T.D. conducted the data analysis. B.G and T.D. drafted the manuscript. M.J. and J.P. revised the draft of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Thibault Duburcq.

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French institutional authority for personal data protection (National Commission for Information Technology and Freedom, registration no DEC20-086) and ethics committee (ID-CRB 2020-A00763-36) approved the study.

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The authors declare that they have no competing interests.

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Garcia, B., Cousin, N., Bourel, C. et al. Prone positioning under VV-ECMO in SARS-CoV-2-induced acute respiratory distress syndrome. Crit Care 24, 428 (2020).

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  • COVID-19
  • Prone positioning
  • ECMO
  • Refractory hypoxemia