Nursing the patient with ARDS: lung-protective ventilation, oxygenation goals, fluids and positioning
- Safe practice
Low tidal volumes by predicted weight, plateau pressure checks, the ordered oxygen target, careful fluids and prone position when ordered.
What it is
In ARDS the lungs are stiff and unevenly injured, and the ventilator itself can add injury. Care follows a lung-protective protocol agreed by the team: low tidal volumes calculated from predicted body weight, a limited plateau pressure, PEEP and FiO2 adjusted by protocol, a conservative fluid strategy when there is no hypoperfusion, and prone position in moderate to severe cases. The nurse makes the protocol work at the bedside: accurate height, careful checks, no unnecessary disconnections, strict fluid balance, prevention of complications and early warning of deterioration. The disease itself is described on the ARDS condition page.
What it requires
- A lung-protective ventilation protocol agreed by the team.
- Arterial blood gases, and often an arterial line for invasive blood pressure.
- Staff trained to turn the patient prone.
- Strict fluid balance and daily weight when the protocol asks for it.
Components
- Low tidal volume by predicted body weight and a limited plateau pressure.
- PEEP and FiO2 adjusted by a protocol table or as ordered.
- An oxygenation target set by the team.
- Conservative fluid strategy without hypoperfusion.
- Prone position for moderate to severe ARDS.
- Sedation, and neuromuscular blockers only in selected situations, not routinely.
How it is applied (and why)
- Measure height accurately and confirm sex for predicted body weight — tidal volume targets depend on it, not on actual weight.
- Check the delivered tidal volume against the ordered target at each check — larger volumes injure the lung.
- Measure the plateau pressure with an inspiratory pause at least every 4 h and after changes; report it above 30 cmH2O.
- Change FiO2 and PEEP only as the protocol or order says, watching SpO2, blood pressure and comfort — PEEP can lower blood pressure.
- Use in-line suction and avoid disconnecting; if it is needed, clamp the tube as the protocol says — loss of PEEP collapses lung units.
- Keep a strict fluid balance and report a rising positive balance — a conservative strategy shortens ventilation.
- Prepare for prone position when PaO2/FiO2 stays below 150 mmHg — long prone sessions reduce mortality.
- Assess sedation and comfort; if a neuromuscular blocker is ordered, confirm adequate sedation first — a paralysed patient cannot show distress.
- Prevent complications: head up, oral care, turning, early enteral feeding and mobilisation when stable.
- Watch for pneumothorax: sudden high pressures, falling SpO2, unequal chest movement or hypotension — call at once.
In nursing practice
- Permissive hypercapnia is accepted: a higher PaCO2 is tolerated to keep volumes and pressures low.
- Neuromuscular blockers are not used routinely; they may be considered for severe asynchrony or refractory hypoxaemia.
- Prolonged high-pressure recruitment manoeuvres are not recommended (ESICM).
- For refractory hypoxaemia despite lung-protective ventilation, the team may consider referral for ECMO in expert centres.
Common mistakes
- Using the actual body weight instead of the predicted body weight.
- Not measuring the plateau pressure after changes.
- Giving extra fluid when there is no sign of hypoperfusion.
- Delaying prone position, or stopping daily prone sessions only because oxygenation did not improve.
Test yourself
Think of the answer, then tap the question to see it.
On what weight is the lung-protective tidal volume based?
On predicted body weight, calculated from sex and height, not on the actual weight.
What plateau pressure limit does WHO give for lung-protective ventilation?
Below 30 cmH2O, checked with an inspiratory pause at least every 4 hours and after changes.
Why is a conservative fluid strategy used in ARDS without hypoperfusion?
It shortens the time on mechanical ventilation.
When is prone position recommended in ARDS?
In moderate to severe ARDS with PaO2/FiO2 below 150 mmHg despite optimised ventilation, in long sessions (WHO 12–16 h; ESICM 16 h or more).
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Clinical management of COVID-19: living guideline, 18 August 2023 (World Health Organization, 2023); Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), tools 9.9 and 9.14 (World Health Organization, 2022); ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies (Intensive Care Medicine (open access, PMC), 2023); Prone position in ARDS patients: why, when, how and for whom (Intensive Care Medicine (open access, PMC), 2020).
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Representative model, for educational purposes only.