THE BATTLE FOR ARDS SURVIVAL: ECMO PRONE POSITIONING VS HIGH PEEP VENTILATION – A META-ANALYTIC INSIGHT

Abstract

Background:

Acute Respiratory Distress Syndrome (ARDS) continues to be a key issue in critical care with increase mortality rate even though the advancements are made in its management. Improving the patient’s prognosis requires imperative respiratory assistance. This meta analysis intends to rule out the potency of three major key interventions: extracorporeal membrane oxygenation (ECMO), prone position and high positive end expiratory pressure (PEEP).

Methodology:

A systematic literature search (January 2000 to July 2025) was conducted across PubMed, Google Scholar and PEDro. Six eligible studies were identified that compared outcomes of extracorporeal membrane oxygenation (ECMO), prone positioning, and high positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS).

Statistical analysis was performed using Review Manager (Rev Man) v5.4. The risk of bias was assessed using the Cochrane RoB 2.0 tool. The outcomes analyzed included mortality rate and length of ventilator free days. Data analysis employed a random-effects model with inverse variance weighting, presenting results as odds ratio (ORS) or mean differences (MDs) with their 95% confidence intervals (CIs). Heterogeneity was assessed using Higgins I^2 statistics. As this study uses previously published data, it did not require institutional ethical review; however, all included studies had received ethical approval from their respective institutional review boards.10

Results:

Our analysis included six randomized controlled trials comprising a total of 761 patients with acute respiratory distress syndrome (ARDS), comparing extracorporeal membrane oxygenation (ECMO), prone positioning, and high positive end-expiratory pressure(PEEP) ventilation strategies. All included trials were assessed as having a low risk of bias.

The pooled analysis demonstrated that extracorporeal membrane oxygenation (ECMO), prone positioning was associated with a significantly lower mortality rate compared with high PEEP ventilation (OR=0.71; 95% CI: 0.52-0.75; p=0.05; I^2=0%). No significant differences were observed among the interventions regarding length of ventilator free days (MD=3.90 days;95% CI: 2.99-4.00; p=0.83; I^2=0%).

Conclusion:

Our study shows that ECMO, prone positioning are effective strategies for managing ARDS, as they significantly improve oxygenation (PaO2/FiO2 ratio) and reduce the risk of mortality compared with high PEEP ventilation alone. However, no significant differences were observed among the interventions in terms of length of ventilator free days. Future large-scale randomized controlled trials are warranted to further validate these findings and to determine the optimal sequencing or combination of these strategies in patients with ARDS.