Management Patterns and Outcomes of Invasive Mechanical Ventilation in Patients With Cardiogenic Shock

Approximately one-half of patients with cardiogenic shock (CS) require invasive mechanical ventilation (IMV). Much of the data regarding IMV management is extrapolated from other populations, and little is known regarding management and outcomes of patients with CS who require IMV.

This study aims to provide data on IMV management in a CS-specific cohort.

Retrospective study of 104 patients treated for CS requiring IMV at an academic safety net hospital from 2017 to 2023. Indications for IMV, ventilator settings, and medications were obtained. Outcomes included in-hospital mortality, survival to extubation, and reintubation.

Reasons for intubation included ongoing cardiac arrest (37%) and hypoxic respiratory failure (32%). Most were on low-level ventilator support 24 hours after intubation (median fraction of inspired oxygen 40% [IQR: 30%-50%], positive end-expiratory pressure 5 cm H₂O [IQR: 5-8]). Spontaneous breathing trials were delayed in 78%, primarily due to hemodynamic instability (82%). Nonpalliative extubation occurred in 62% after a median of 4.8 days (IQR: 2.3-8.0). Among patients who received temporary mechanical circulatory support (tMCS) (49%) and survived, tMCS was removed before extubation in 98%. Reintubation occurred in 14% within 48 hours, and in-hospital mortality was 41%.

In this cohort, patients were frequently on minimal ventilator support within 24 hours of intubation, yet spontaneous breathing trials and extubation were delayed due to hemodynamic instability. Rates of failed extubation were comparable to other forms of critical illness. Further research is necessary to determine optimal approaches to ventilator liberation in patients with CS, particularly when hemodynamic derangements or tMCS persist in patients who are otherwise candidates for extubation.