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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Critical Care

Advanced Options: Prone Positioning and ECMO

At a Glance

When ventilators cannot provide enough oxygen for severe acute lung injury, ICU teams use rescue therapies like prone positioning (turning the patient on their stomach) and ECMO (an artificial lung machine). These advanced treatments improve oxygen levels and allow damaged lungs to rest and heal.

When standard ventilator settings are not enough to keep oxygen at safe levels, the ICU team may move to “rescue therapies.” These are advanced techniques designed to support the body during the most critical stages of ARDS. These interventions are typically used when a patient develops refractory hypoxemia—a medical term for oxygen levels that remain dangerously low despite using the best possible ventilator settings [1][2].

Prone Positioning: The Power of the “Flip”

In a typical hospital bed, patients lie on their backs (the supine position). However, for a patient with severe ARDS, the weight of the heart and the fluid-filled lungs can compress the back-side of the lungs, making it impossible for air to reach them.

Prone positioning involves carefully turning the patient onto their stomach for 12 to 20 hours a day [3][4]. This simple change in gravity has profound effects:

  • Recruiting the Lungs: It opens up the large sections of the lungs in the back that were previously squashed and filled with fluid [5][6].
  • Even Distribution: It helps the ventilator spread air more evenly across the lungs, which reduces “hot spots” of high pressure that cause injury [5][7].
  • Heart Support: It can reduce the strain on the right side of the heart by making it easier for the heart to pump blood through the lungs [8][9].

Prone positioning is a standard treatment for patients with a P/F ratio below 150 [3][1].

ECMO: The “Artificial Lung”

If prone positioning and high ventilator settings still cannot provide enough oxygen, the team may discuss Venovenous ECMO (Extracorporeal Membrane Oxygenation).

Think of ECMO as a bypass machine for the lungs. It does not “cure” the lungs; instead, it does their job for them so they can rest completely [10][11].

  • The Mechanism: Blood is taken out of the body through a large tube (cannula), pumped through an “oxygenator” (the artificial lung) where oxygen is added and carbon dioxide is removed, and then warmed and returned to the body [10][12].
  • The Goal: By taking over the work of breathing, ECMO allows the medical team to turn the ventilator down to “ultra-protective” settings. This prevents the ventilator from causing any further damage while the lungs try to heal [13][14].

When is it Time to Escalate?

The decision to move to these therapies is based on specific “trigger” numbers. Doctors generally consider these options when:

  1. Oxygen is too low: The P/F ratio is consistently below 100 or 150 [15][3].
  2. CO2 is too high: The body cannot get rid of carbon dioxide, causing the blood to become too acidic [16][17].
  3. Lungs are too “stiff”: The pressure needed to move air is so high that it risks rupturing the lung tissue [18][16].

While these therapies are life-saving, they are also complex. Prone positioning requires a large team to safely “flip” the patient, and ECMO requires specialized equipment and carries risks like bleeding [4][19]. Your medical team will weigh these risks carefully against the potential benefits for your loved one.

Common questions in this guide

What is prone positioning in the ICU?
Prone positioning involves carefully turning a patient onto their stomach, usually for 12 to 20 hours a day. This change in gravity opens up compressed areas in the back of the lungs, distributes air more evenly from the ventilator, and improves overall oxygen levels.
How does an ECMO machine work for lung injury?
ECMO acts as an artificial lung for patients with severe lung injury. It pumps blood outside the body through an oxygenator that adds oxygen and removes carbon dioxide, which allows the medical team to turn down the ventilator so the patient's actual lungs can rest.
When do doctors decide to use ECMO or prone positioning?
Doctors consider these rescue therapies when a patient's oxygen levels remain dangerously low despite optimal ventilator settings. They are also triggered when carbon dioxide levels become too high and acidic, or when the lungs become dangerously stiff.
What are the primary risks of using ECMO?
Because ECMO is a highly complex life-support system, it carries significant medical risks. The most common primary risks families should be prepared for include severe bleeding and the potential for serious infections.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How long has my loved one's P/F ratio been below 150, and at what point do we consider prone positioning?
  2. 2.Is the goal of prone positioning to improve oxygen levels, or are we trying to prevent further lung injury by spreading the air more evenly?
  3. 3.What specific criteria would trigger the team to discuss ECMO as a 'rescue' therapy?
  4. 4.If we move to ECMO, what are the primary risks, such as bleeding or infection, that we should be prepared for?
  5. 5.How many hours a day will they remain in the prone position, and how is their skin and airway being protected during the flip?

Questions For You

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References

References (19)
  1. 1

    Factors associated with a nonresponse to prone positioning in patients with severe acute respiratory distress syndrome due to SARS-CoV-2.

    Sanabria-Rodríguez OO, Cardozo-Avendaño SL, Muñoz-Velandia OM

    Critical care science 2023; (35(2)):156-162 doi:10.5935/2965-2774.20230343-en.

    PMID: 37712804
  2. 2

    Improved Oxygenation After Prone Positioning May Be a Predictor of Survival in Patients With Acute Respiratory Distress Syndrome.

    Lee HY, Cho J, Kwak N, et al.

    Critical care medicine 2020; (48(12)):1729-1736 doi:10.1097/CCM.0000000000004611.

    PMID: 33003079
  3. 3

    Efficacy of prone position in acute respiratory distress syndrome: overview of systematic reviews.

    Dalmedico MM, Salas D, Oliveira AM, et al.

    Revista da Escola de Enfermagem da U S P 2017; (51()):e03251 doi:10.1590/S1980-220X2016048803251.

    PMID: 29019530
  4. 4

    Prone Position for Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis.

    Munshi L, Del Sorbo L, Adhikari NKJ, et al.

    Annals of the American Thoracic Society 2017; (14(Supplement_4)):S280-S288 doi:10.1513/AnnalsATS.201704-343OT.

    PMID: 29068269
  5. 5

    Effect of body position on the redistribution of regional lung aeration during invasive and non-invasive ventilation of COVID-19 patients.

    Dos Santos Rocha A, Diaper J, Balogh AL, et al.

    Scientific reports 2022; (12(1)):11085 doi:10.1038/s41598-022-15122-9.

    PMID: 35773299
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    Effect of the prone position on recruitability in acute respiratory distress syndrome due to COVID-19 pneumonia.

    Emgin Ö, Rollas K, Yeniay H, et al.

    Revista da Associacao Medica Brasileira (1992) 2023; (69(5)):e20221120 doi:10.1590/1806-9282.20221120.

    PMID: 37222316
  7. 7

    Prone Positioning Improves Ventilation Homogeneity in Children With Acute Respiratory Distress Syndrome.

    Lupton-Smith A, Argent A, Rimensberger P, et al.

    Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2017; (18(5)):e229-e234 doi:10.1097/PCC.0000000000001145.

    PMID: 28328787
  8. 8

    Severe Acute Respiratory Distress Syndrome in Potential Organ Donors-Rescue Prone Positioning: A Case Report.

    Dyla A, Zając M, Mielnicki W

    Transplantation proceedings 2021; (53(4)):1342-1344 doi:10.1016/j.transproceed.2020.10.037.

    PMID: 33358525
  9. 9

    Experts' opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation.

    Vieillard-Baron A, Matthay M, Teboul JL, et al.

    Intensive care medicine 2016; (42(5)):739-749 doi:10.1007/s00134-016-4326-3.

    PMID: 27038480
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    Extracorporeal Strategies in Acute Respiratory Distress Syndrome.

    Cavayas YA, Thakore A, Fan E

    Seminars in respiratory and critical care medicine 2019; (40(1)):114-128 doi:10.1055/s-0039-1685191.

    PMID: 31060093
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    Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases.

    Ramanathan K, Antognini D, Combes A, et al.

    The Lancet. Respiratory medicine 2020; (8(5)):518-526 doi:10.1016/S2213-2600(20)30121-1.

    PMID: 32203711
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    Extracorporeal Support for Acute Respiratory Distress Syndrome.

    Greendyk R, Abrams D, Agerstrand C, et al.

    Clinics in chest medicine 2024; (45(4)):905-916 doi:10.1016/j.ccm.2024.08.012.

    PMID: 39443007
  13. 13

    Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study.

    Guervilly C, Fournier T, Chommeloux J, et al.

    Critical care (London, England) 2022; (26(1)):383 doi:10.1186/s13054-022-04272-x.

    PMID: 36510324
  14. 14

    Mechanical Ventilation for Acute Respiratory Distress Syndrome during Extracorporeal Life Support. Research and Practice.

    Abrams D, Schmidt M, Pham T, et al.

    American journal of respiratory and critical care medicine 2020; (201(5)):514-525 doi:10.1164/rccm.201907-1283CI.

    PMID: 31726013
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    Clinician Recognition of the Acute Respiratory Distress Syndrome: Risk Factors for Under-Recognition and Trends Over Time.

    Schwede M, Lee RY, Zhuo H, et al.

    Critical care medicine 2020; (48(6)):830-837 doi:10.1097/CCM.0000000000004328.

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    Right ventricular injury in patients with COVID-19-related ARDS eligible for ECMO support: a multicenter retrospective study.

    Petit M, Bouaoud M, Jullien E, et al.

    Annals of intensive care 2024; (14(1)):40 doi:10.1186/s13613-024-01256-8.

    PMID: 38532049
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    Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis.

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    Effect of Lowering Vt on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance.

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This page explains advanced ICU treatments like prone positioning and ECMO for educational purposes. Because acute lung injury is a critical condition, always consult your ICU team for specific medical guidance regarding your loved one's care.

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