Acute respiratory distress syndrome (ARDS) is a severe lung condition characterized by diffuse alveolar damage and hypoxemia. Venovenous extracorporeal membrane oxygenation (vv-ECMO) supports gas exchange and reduces ventilator-induced injury, while prone positioning (PP) improves oxygenation by optimizing ventilation-perfusion matching.

We conducted a systematic review and meta-analysis, following PRISMA guidelines, using MEDLINE, Embase, and the Cochrane Library. Studies included were on adult ARDS patients undergoing vv-ECMO with PP. Outcomes measured were survival rates, ECMO weaning, duration of ECMO support, mechanical ventilation, ICU and hospital stays, and complications.

Seventeen studies met inclusion criteria. While ECMO+PP improved 30-day and hospital survival rates, there was no significant improvement in 60-day survival, 90-day survival, ICU survival, or ECMO weaning rates. ECMO+PP significantly enhanced oxygenation parameters and reduced PaCO2 levels. Earlier and more frequent PP sessions shortened mechanical ventilation and ICU stays. Non-COVID patients had better 30-day survival with ECMO+PP than COVID patients.

Combining PP with ECMO improves early but not long-term survival in severe ARDS, especially in non-COVID patients, while extending duration of mechanical support and stays. Further prospective randomized trials are needed to confirm these findings.