Unproven and Expensive before Proven and Cheap: Extracorporeal Membrane Oxygenation versus Prone Position in Acute Respiratory Distress Syndrome

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Abstract
We identified 810 reports that described ECMO in ARDS, and 61 fulfilled our inclusion criteria (Figure). 61 reports were included, and the authors of 26 (43%) responded to email requests for confirmation (or clarification). Based on the aggregate (published and emailed) information, 9 papers were excluded because key data were unclear; unambiguous data were available relating to 17 papers. These 17 papers represented 672 patients with ARDS who were cannulated with VV-ECMO; of these patients, 208 (31%) received a trial of prone positioning before ECMO, and 464 (69%) did not. The proportion of studies that clearly identified whether prone positioning was used prior to ECMO was similar before (30% of 20 papers) and after (34% of 32 papers) the publication in 2013 of a key RCT reporting a survival benefit associated with prone positioning (P>0.05) (3). However, the proportion of all VV-ECMO patients in whom prone positioning was used before ECMO was lower in the more recent studies (84/452, 19%) vs. those published before 2013 (124/220, 56%; P<0.05). These data suggest a systematic bias in the literature reporting outcomes after ECMO. The vast majority of reported patients who receive ECMO did not first receive therapy that (in contrast to ECMO), is simple, cheap and of proven benefit; therefore, inferences about the efficacy of ECMO in ARDS are of limited use.

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