Proning and PEEP with Ben Creagh-Brown

Ben Creagh-Brown from Guildford gives us his tips to manage a case with ARDS

Ben takes questions after his excellent talk on PEEP and proning

We start with some! fun. This gives an interactive aspect to his excellent talk.

When the patient has respiratory failure, what do you do next?

The most frequent response was intubate and ventilate, with nasal high-flow oxygen following second. NIV seems unpopular.

How do you optimise PEEP?

By far the most popular answer is a recruitment and detrimental PEEP trial. Ben goes on to explain this in more detail. PEEP of 40cmH2O??!?! Anyone that brave?

Do you understand transpulmonary pressure and it’s use for PEEP setting?

Mostly, the audience say “Yes I’ve heard of it, but I don’t use it”. Ben explained it’s the “true distending pressure of the lung”. Mathematically it’s the alveolar pressure minus the pleural pressure. By measuring the oesophageal pressure it is possible to know that lung units remain recruited and not collapsed.

In conclusion, the international consensus decided that higher PEEP is probably better than lower PEEP. Subsequent observational data suggests that initial PEEP used is only 8–10 cmH2O. So are we getting it wrong?

Ben’s conclusions:

  • In mod/severe ARDS, high PEEP better than lower PEEP
  • Individualised PEEP probably even better if you have the time / tech to do it
  • Further trials are looking at “open lung” strategy and transpulmonary pressure use.

Would you prone him?

Almost a consensus… yes. A small fraction say “I don’t think it’s useful” or “He doesn’t need it”.

Ben explains that physiologically it makes sense but the evidence of mortality benefit and harms don’t conclusively back this up.

  • Ironing is associated with mortality benefit in severe ARDS
  • Harm can occur
  • It requires a lot of resource to perform


  • Individualise PEEP
  • Optimise fully then prone
  • Consider referral to ECMO centre early