[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Critical care](https://durgical.com/en/nursing/areas/critical-care/) › Nursing the patient with ARDS: lung-protective ventilation, oxygenation goals, fluids and positioning # 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. Updated Nov 13, 2026 ## Key points - Low tidal volumes calculated from predicted body weight, as the protocol says; predicted weight comes from sex and height, so measure height. - Plateau pressure below 30 cmH2O (WHO), checked at least every 4 h and after each PEEP or volume change. - Oxygenation goal in the ARDSNet protocol of the WHO toolkit: PaO2 55–80 mmHg or SpO2 88–95%, unless the team sets another. - Conservative fluids when there is no hypoperfusion: it shortens time on the ventilator. - Prone position for PaO2/FiO2 below 150 mmHg, in long sessions (WHO 12–16 h; ESICM 16 h or more). - Avoid disconnections: in-line suction, and clamp the tube as the protocol says if a disconnection is needed. ## 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). [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/nursing-the-patient-with-ards-lung-protective-ventilation-oxygenation-goals-flui/) ## Elsewhere in DurgiPedia - [Oxygenation: SpO₂, PaO₂, cyanosis and oxygen therapy](https://durgical.com/en/physiology/oxygenation-spo-pao-cyanosis-and-oxygen-therapy/) ## Connections ## Related 3 - [Caring for the ventilated patient: modes and settings in general terms, the hourly check and what to record](https://durgical.com/en/nursing/caring-for-the-ventilated-patient-modes-and-settings-in-general-terms-the-hourly/) - [Prone positioning: the team, the turn, protecting tubes, eyes and pressure points](https://durgical.com/en/nursing/prone-positioning-the-team-the-turn-protecting-tubes-eyes-and-pressure-points/) - [The patient on neuromuscular blockers: sedation first, train-of-four, eye care and skin](https://durgical.com/en/nursing/the-patient-on-neuromuscular-blockers-sedation-first-train-of-four-eye-care-and/) ## Related conditions 1 - [Acute respiratory distress syndrome (ARDS)](https://durgical.com/en/conditions/acute-respiratory-distress-syndrome/) [← All of nursing](https://durgical.com/en/nursing/) 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](https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2023.2) (World Health Organization, 2023); [Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), tools 9.9 and 9.14](https://www.who.int/publications/i/item/clinical-care-of-severe-acute-respiratory-infections-tool-kit) (World Health Organization, 2022); [ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies](https://pmc.ncbi.nlm.nih.gov/articles/PMC10354163/) (Intensive Care Medicine (open access, PMC), 2023); [Prone position in ARDS patients: why, when, how and for whom](https://pmc.ncbi.nlm.nih.gov/articles/PMC7652705/) (Intensive Care Medicine (open access, PMC), 2020). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/nursing-the-patient-with-ards-lung-protective-ventilation-oxygenation-goals-flui/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/nursing-the-patient-with-ards-lung-protective-ventilation-oxygenation-goals-flui/