ICM:VV-ECMO期间俯卧位：一项系统评价与荟萃分析

Abstract

Purpose: The evidence supporting the benefit on clinical outcomes of prone positioning during veno-venous extracorporeal membrane oxygenation (V-V ECMO) for acute hypoxemic respiratory failure remains inconclusive. We aimed to assess the association of prone positioning, compared to no prone positioning, with 28-day mortality and other clinical outcomes in different patient subgroups.目前支持急性低氧性呼吸衰竭患者在接受静脉 – 静脉体外膜肺氧合（V – V ECMO）期间采用俯卧位对临床结局有益的证据尚无定论。本研究旨在评估与不采用俯卧位相比，俯卧位与不同患者亚组中 28 天死亡率及其他临床结局之间的关联。

Methods: A systematic review and meta-analysis of randomized and non-randomized controlled trials (RCTs) using a random-effects model was conducted. An electronic database search up to September 1st, 2024 was performed (PROSPERO CRD42024517602). The RoB 2 and ROBINS-I tools were used for risk of bias assessments.采用随机效应模型对随机对照试验（RCTs）和非随机对照试验进行系统评价和荟萃分析。检索电子数据库截至 2024 年 9 月 1 日（PROSPERO CRD42024517602）。使用 RoB 2 和 ROBINS – I 工具进行偏倚风险评估。

Results: We analyzed two RCTs and 20 non-RCTs (3,465 patients). Compared to no prone positioning, the use of prone positioning was associated with lower 28-day (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42-0.98, p = 0.040, I² = 66%, low certainty of evidence [CoE]) and hospital mortality (OR 0.67, 95% CI 0.54-0.83, p < 0.001, I² = 39%, low CoE), despite fewer 28-day ventilator-free days and longer ECMO duration. Younger age (p = 0.005), a higher sequential organ failure assessment (SOFA) score (p = 0.022), non-Covid-19 etiology (p = 0.003), and lower rates of prone positioning before cannulation (p = 0.049) were associated with a greater benefit from prone positioning.本研究分析了 2 项 RCTs 和 20 项非 RCTs（共 3465 例患者）。与不采用俯卧位相比，采用俯卧位可使 28 天死亡率（比值比[OR] 0.64，95% 置信区间[CI] 0.42 – 0.98，P = 0.040，I² = 66%，证据确定性[CoE] 低）和住院死亡率（OR 0.67，95% CI 0.54 – 0.83，P < 0.001，I² = 39%，CoE 低）降低，尽管俯卧位组患者的 28 天无呼吸机天数较少且体外膜肺氧合使用时间更长。年龄较小（P = 0.005）、序贯器官衰竭评估（SOFA）评分较高（P = 0.022）、非新冠病因（P = 0.003）以及插管前俯卧位实施率较低（P = 0.049）的患者从俯卧位治疗中获益更大。

Conclusion: In this analysis, among patients supported with V-V ECMO for acute hypoxemic respiratory failure, we observed improved 28-day and hospital mortality in those who received prone positioning, compared to those who did not. However, these findings do not imply causation. Further research is needed to clarify the role of prone positioning in this population.在本分析中，对于接受 V – V ECMO 支持的急性低氧性呼吸衰竭患者，与未采用俯卧位者相比，接受俯卧位治疗的患者 28 天和住院死亡率有所改善。然而，这些研究结果并不意味着存在因果关系。需要进一步的研究来明确俯卧位在该人群中的作用。