CCRN Respiratory Review (12%): ARDS, Ventilator Complications, and Pleural Emergencies

The respiratory category: 12% and 13 listed problems

Respiratory is 12% of the Adult CCRN Test Plan for exams taken on and after November 12, 2025, or about 15 of the 125 scored questions (Passy estimate; AACN publishes only the percentage). The 13 listed problems are acute pulmonary edema, acute pulmonary embolus, ARDS, acute respiratory failure, acute respiratory infection, chronic conditions such as COPD and asthma, mechanical ventilation complications, pleural space abnormalities, pulmonary hemorrhage, pulmonary hypertension, status asthmaticus, thoracic and airway trauma, and thoracic surgery.

Compared with the 2020 list, acute pulmonary edema moved here from Cardiovascular, and pulmonary hemorrhage is newly named. The 2025 list no longer names pulmonary fibrosis or aspiration, and it says "mechanical ventilation complications" where the 2020 list said "failure to wean." The respiratory nursing actions include airway management, chest tubes, mechanical ventilation, noninvasive ventilation and high-flow nasal cannula, prevention of ventilator complications, prone positioning, rapid sequence intubation, monitoring devices such as SpO2, SvO2 and ETCO2, thoracentesis and tracheostomy.

Lung-protective ventilation: tidal volume by predicted body weight

Three guideline documents agree on the core of ARDS ventilation, with different strengths:

• ATS 2024 update: it keeps the 2017 strong recommendations to limit tidal volume to 4–8 mL/kg of predicted body weight (PBW) with a plateau pressure below 30 cm H2O, and to prone patients with severe ARDS for more than 12 hours a day.
• Surviving Sepsis Campaign 2026, sepsis with ARDS: it recommends a low tidal volume of 6 mL/kg over a high one above 10 mL/kg, and an upper plateau goal of 30 cm H2O. It suggests higher rather than lower PEEP, and prone ventilation for more than 12 hours daily, in moderate to severe ARDS.
• Surviving Sepsis Campaign 2021 text: it describes the practical step of lowering tidal volume over 1 to 2 hours toward about 6 mL/kg PBW while keeping plateau pressure at or below 30 cm H2O, and raising the respiratory rate up to 35 breaths/min to hold minute ventilation. It notes that the resulting hypercapnia appears to be tolerated in the absence of contraindications such as high intracranial pressure.

The weight in every one of these numbers is predicted, not actual. The MSD Manual's ARDS chapter (reviewed June 2026) states it directly: ideal body weight rather than actual body weight sets the tidal volume. The examples below give PBW so the arithmetic stays visible.

Example 1 (fictional). A patient with moderate ARDS has a PBW of 70 kg.

• The 4–8 mL/kg range is 280 to 560 mL.
• At 6 mL/kg, the target is 6 × 70 = 420 mL.
• If the plateau pressure on 420 mL is 27 cm H2O, both limits are met.

Example 2 (fictional): why actual weight misleads. A woman with ARDS has a PBW of 55 kg and an actual weight of 92 kg. Her tidal volume is set at 550 mL, and the plateau pressure during an inspiratory hold is 32 cm H2O.

• On actual weight, 550 mL looks like 6 mL/kg (550 ÷ 92 ≈ 6.0).
• On PBW it is 10 mL/kg (550 ÷ 55), the high-volume end that SSC compares against.
• The plateau pressure is above 30.
• So the change to anticipate is a stepwise reduction toward about 330 mL (6 × 55), with a higher rate to protect minute ventilation, then a fresh plateau check.

A larger body does not mean larger lungs, so multiplying by the number on the scale over-inflates them. The plateau reading is meaningful only when the patient is passive during the inspiratory hold, a point the SSC 2021 text makes. Once the two examples feel routine, check your PBW tidal volume math on the free CCRN ARDS item →, which uses a new set of weights and pressures.

Peak versus plateau pressure: a troubleshooting table

The MSD Manual's overview of mechanical ventilation (reviewed June 2026) explains the split. Peak pressure is the total pressure needed to push a breath in. When peak pressure rises unexpectedly, assess the patient and circuit and measure plateau with an appropriate inspiratory hold if the patient is passive. Interpret the change against tidal volume, flow, PEEP, and the prior readings. Peak minus plateau is the resistive part, and plateau minus PEEP is the elastic part.

A stem that gives you both pressures is asking which half of the problem moved. A blocked tube raises only the peak; a pneumothorax or a tube in one mainstem bronchus raises both.

When a ventilated patient crashes: a sudden-deterioration checklist

The MSD Manual's pneumothorax chapter (reviewed July 2025) says tension pneumothorax most often occurs in patients on positive-pressure ventilation. Sudden hypotension in a ventilated patient should prompt the thought. If breath sounds are also decreased and the chest is hyperresonant, tension pneumothorax should be presumed and treated at once, without waiting for a chest radiograph. Treatment is needle decompression followed immediately by tube thoracostomy.

1. Call for urgent help and assess the patient before the alarm screen. Check chest rise, breath sounds on both sides, tracheal position, SpO2 and blood pressure.
2. Check the tube. Look for a kinked or bitten tube and for secretions. These raise the peak pressure, usually without sudden hemodynamic collapse.
3. Put the findings together. Sudden hypotension and unilateral absent breath sounds strongly raise concern for tension pneumothorax. Tracheal deviation is a late sign and need not be present; do not wait for it or imaging in an unstable patient.
4. Call for immediate decompression. Decompression is a provider procedure, so the nurse's job is to get the provider to the bedside now, bring the equipment, and prepare for a chest tube right after. A portable film is not a step to wait for.
5. Reassess after each intervention. Recheck pressures, breath sounds, SpO2 and blood pressure, and expect a chest tube drainage system to manage afterward.

The free set's ventilated trauma patient tests steps 3 and 4 under time pressure. After the checklist, work the tension pneumothorax scenario in the free CCRN questions → and compare your first action with the explanation for each option.

Prone positioning and pleural emergencies in plain words

The prone recommendations differ in who they cover. ATS 2024 recommends prone positioning for more than 12 hours a day in severe ARDS (strong). SSC 2026 suggests more than 12 hours daily for moderate to severe ARDS in sepsis. The MSD Manual says at least 12 hours daily for moderate to severe ARDS. Learn the shared core, more than 12 hours a day for patients with significant ARDS, and read the severity wording in any stem carefully. For the nursing side of turning and protecting a patient, AACN's Practice Alert "Manual Prone Positioning in Adults: Reducing the Risk of Harm Through Evidence-Based Practices" is the reference to read.

SSC 2026 also suggests a trial of awake proning for non-intubated patients with sepsis and acute hypoxemic respiratory failure, adding that sedation should not be used to make proning tolerable in that group.

The pleural space problem on the test plan includes pneumothorax, hemothorax, empyema and pleural effusions, and chest tubes and thoracentesis are listed nursing actions. Expect questions on recognizing a collection that is compromising breathing and on managing the drainage system afterward. For the blood gas side of ventilator changes, the CCRN ABG and acid-base guide works through compensation. For ARDS that starts with sepsis, the CCRN sepsis and shock guide covers the first hours. How this category fits the whole exam is in the CCRN (Adult) test plan guide.