Recruitment Maneuvers: Opening Collapsed Lung Without Crashing the Patient

Part of the ICU Emergencies Hub — browse every related guide in one place.

Updated July 2026  |  More ICU clinical guides →

In severe ARDS and other causes of refractory hypoxemia, portions of the lung collapse and stop participating in gas exchange. A recruitment maneuver is a deliberate, transient increase in airway pressure meant to re-open those collapsed alveoli — and then hold them open with adequate PEEP. It can improve oxygenation quickly, but it also transiently raises intrathoracic pressure enough to drop the blood pressure and, occasionally, cause barotrauma. The nurse at the bedside is the one watching the monitor second by second, so understanding the maneuver and its risks is essential. This guide covers what recruitment is, the common methods, the dangers, and the nursing role around it.

Why alveoli collapse, and why re-opening helps

In ARDS the lungs are heavy and inflamed, and dependent regions collapse under their own weight — a phenomenon called atelectasis. Collapsed alveoli receive blood flow but no air, creating shunt: blood returns to the heart just as deoxygenated as it left, which is why the oxygenation stays poor no matter how high the FiO2. Recruitment aims to pop those units back open so they can exchange gas again. Crucially, opening a lung unit takes more pressure than keeping it open, which is the whole logic of the "open lung" approach: use a brief higher pressure to recruit, then set a PEEP high enough that the newly opened alveoli do not collapse again on the next exhalation. Repeatedly opening and slamming shut (atelectrauma) is itself injurious, so stability after recruitment matters as much as the opening.

Common methods

The specific protocol is set by the provider and respiratory therapist; there is no single universal recipe, and practice varies because the evidence on routine aggressive recruitment is mixed. What is consistent across methods is the need for continuous monitoring during the maneuver.

The risks to watch

The dominant risk is hemodynamic. The same high intrathoracic pressure that opens alveoli also compresses the great veins and drops venous return, so blood pressure and cardiac output can fall sharply mid-maneuver — more so in a patient who is hypovolemic or already on pressors. The second risk is barotrauma: forcing pressure into stiff, heterogeneous lungs can rupture the most compliant units, causing a pneumothorax or pneumomediastinum. Transient hypoxemia or arrhythmia can also occur. Because of these risks, recruitment is generally avoided or done with extreme caution in the hemodynamically unstable, the hypovolemic, and those with known bullae or a recent air leak.

The nurse's role around a recruitment maneuver

Before: confirm the plan and abort thresholds with the team, ensure adequate sedation (and often deep sedation or short-term paralysis, since spontaneous effort defeats the maneuver), optimize volume status, and have vasopressors and monitoring ready. During: watch the arterial line, heart rate, rhythm, and SpO2 continuously, and speak up the instant a threshold is crossed. After: help set and document the resulting PEEP, reassess oxygenation and driving pressure/compliance to see whether recruitment actually helped, watch for a delayed pneumothorax (rising pressures, sudden desaturation, unilateral breath sounds, hypotension), and reassess the sedation plan. Recruitment is frequently combined with prone positioning and other refractory-hypoxemia strategies as part of a broader ARDS plan.

Where to go from here

Continue with the lung-protective ventilation guide, PEEP titration, driving and plateau pressure, prone positioning, and inhaled pulmonary vasodilators for refractory hypoxemia.