The ventilator is not neutral

An international registry of 1,010 adults with heart failure-related cardiogenic shock, treated at 16 centers in five countries between 2010 and 2021, found higher 30-day mortality and longer ICU stays in patients who received invasive ventilation, with the same direction of signal even when gas exchange was preserved. The design cannot separate a sicker patient from a harmful intervention. We cover what the study did, the numbers as reported, what an observational registry cannot show, and what it means for respiratory therapists, nurses, pharmacists and intensivists.

In this episode

* 659 of 1,010 patients (65.2%) received invasive ventilation. 30-day mortality was 56.5% with ventilation and 41.1% without; the adjusted hazard ratio was 1.67 (95% confidence interval 1.26 to 2.22).

* The risk followed gas exchange: hazard ratio 1.74 for a PaO2/FiO2 of 100 or less and 1.82 for 101 to 200. Patients with a ratio above 200 trended the same way at 1.39 (0.99 to 1.97, p = 0.06), which did not reach significance.

* Ventilated patients had more cardiac arrests before admission (54.3% against 11.2%) and higher lactate (5.5 against 3.2 mmol/L). The registry did not capture the indication for intubation, ventilator settings, sedation or noninvasive ventilation, so this is an association, not a demonstrated harm.

* In a single-center US cohort of 104 ventilated patients, nearly half were on an FiO2 of 40% or less with a PEEP of 5 cmH2O or less a day after intubation, yet the first spontaneous breathing trial was postponed in 78%, usually for hemodynamic reasons; complications after intubation occurred in 38%, most commonly hypotension.

* ICCN position: name the indication before the induction, plan induction as a hemodynamic event, set PEEP with both ventricles in mind, consider noninvasive support only in carefully selected patients, and start the exit plan on day one.

Read the full article: https://iccn.substack.com/p/the-ventilator-is-not-neutral?utm_source=podcast&utm_medium=audio&utm_campaign=q4_paid

Sources

* Besch L, Kellner C, Sundermeyer J, et al. Invasive ventilation and association with outcomes in heart failure-related cardiogenic shock. Clin Res Cardiol. 2026;115(11):2015-2023. doi:10.1007/s00392-026-02953-z

* El Zarif T, Caraballo C, Victoria-Castro AM, et al. Respiratory support and mortality risk across the spectrum of cardiogenic shock severity. J Soc Cardiovasc Angiogr Interv. 2025;4(12):104043. doi:10.1016/j.jscai.2025.104043

* Sacco A, Montisci A, Tavecchia G, et al. Ventilation strategies in cardiogenic shock: insights from the AltShock-2 registry. Eur J Heart Fail. 2024;26(11):2412-2420. doi:10.1002/ejhf.3409

* Volle K, Merdji H, Bataille V, et al. Ventilation strategies in cardiogenic shock: insights from the FRENSHOCK observational registry. Clin Res Cardiol. 2025;114(10):1311-1323. doi:10.1007/s00392-024-02551-x

* Grubb CS, Tucker G, Bionghi N, et al. Management patterns and outcomes of invasive mechanical ventilation in patients with cardiogenic shock. JACC Adv. 2025;4(10 Pt 1):101916. doi:10.1016/j.jacadv.2025.101916

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This episode is for educational purposes for healthcare professionals. It is not medical advice, a clinical guideline or a standard of care. Clinical decisions must be individualized by qualified clinicians.

Hosted by Javier Amador-Castaneda, BHS, RRT, FCCM. Voices rendered with AI text-to-speech from a script written and reviewed by ICCN.

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