{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,5]],"date-time":"2026-11-05T11:04:19Z","timestamp":1793876659108,"version":"4.7.0"},"reference-count":14,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T00:00:00Z","timestamp":1784851200000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>Optimal positive end-expiratory pressure (PEEP) selection in cardiogenic shock (CS) remains poorly defined despite the frequent use of invasive mechanical ventilation in this population. We aimed to evaluate whether a respiratory mechanics\u2013guided PEEP titration protocol results in clinically relevant changes in ventilator settings and to assess the haemodynamic consequences of these adjustments.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>A prospective physiological study was conducted in mechanically ventilated patients with CS undergoing a decremental PEEP titration protocol (15 to 5 cmH2O). The final PEEP was selected according to maximal respiratory system compliance without evidence of derecruitment, overdistension, or haemodynamic deterioration. Haemodynamic, echocardiographic, and respiratory parameters were assessed at each step. Twenty-five patients were included, including 15 with acute myocardial infarction\u2013related CS (AMI-CS) and 10 with heart failure\u2013related CS (HF-CS). PEEP titration resulted in modification of ventilatory settings in 88% of patients. PEEP reduction occurred predominantly in AMI-CS, whereas PEEP escalation was more common in HF-CS. Respiratory mechanics and oxygenation improved following titration, with higher static compliance (62.5 \u00b1 11 vs. 74.7 \u00b1 11.5 mL\/cmH2O; P = 0.003) and PaO2\/FiO2 ratio (244 \u00b1 89 vs. 276 \u00b1 65; P = 0.001). Right atrial pressure (RAP) varied significantly across PEEP levels (P &amp;lt; 0.001) and changes were greater in HF-CS and in patients with RV dysfunction. Patients with impaired RV function showed greater RAP increase and reduced tolerance to higher PEEP levels.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Respiratory mechanics\u2013guided PEEP titration frequently modifies ventilatory settings in CS and reveals marked variability in haemodynamic tolerance according to CS phenotype and RV function. Individualized PEEP titration may help balance respiratory benefit, congestion, and haemodynamic stability in mechanically ventilated patients with CS.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjacc\/zuag099","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T11:58:58Z","timestamp":1784721538000},"source":"Crossref","is-referenced-by-count":1,"title":["PEEP titration in cardiogenic shock: impact on congestion and haemodynamic phenotype"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9560-5138","authenticated-orcid":false,"given":"Guido","family":"Tavazzi","sequence":"first","affiliation":[{"name":"Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia , Pavia ,","place":["Italy"]},{"name":"Fondazione IRCCS Policlinico S. Matteo, Intensive Care , Viale Golgi 19, Pavia 27100 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2330-7641","authenticated-orcid":false,"given":"Alessandro","family":"Fasolino","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University of Milano-Bicocca , Via Cadore 48, Monza 20900 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1628-3642","authenticated-orcid":false,"given":"Costanza Natalia Julia","family":"Colombo","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS Policlinico S. Matteo, Intensive Care , Viale Golgi 19, Pavia 27100 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4400-5001","authenticated-orcid":false,"given":"Marco","family":"Pozzi","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS Policlinico S. Matteo, Intensive Care , Viale Golgi 19, Pavia 27100 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5151-6400","authenticated-orcid":false,"given":"Christophe","family":"Vandenbriele","sequence":"additional","affiliation":[{"name":"Department of Anesthesia, Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, Guy's & St. Thomas\u2019 NHS Foundation Trust , London ,","place":["UK"]},{"name":"Heart Center , Aalst ,","place":["Belgium"]},{"name":"Department of Surgery and Cancer, Faculty of Medicine, Imperial College , London ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3488-8903","authenticated-orcid":false,"given":"Federico","family":"Capra Marzani","sequence":"additional","affiliation":[{"name":"Fondazione IRCCS Policlinico S. Matteo, Intensive Care , Viale Golgi 19, Pavia 27100 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos L","family":"Alviar","sequence":"additional","affiliation":[{"name":"Leon H Charney Division of Cardiology, New York University Grossman School of Medicine , New York, NY ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5588-2608","authenticated-orcid":false,"given":"Francesco","family":"Corradi","sequence":"additional","affiliation":[{"name":"Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa , Pisa ,","place":["Italy"]},{"name":"Anesthesia and Critical Care Department, Azienda Tutela Della Salute Liguria , La Spezia ASL 5 ,","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,7,24]]},"reference":[{"key":"2026073121215118800_zuag099-B1","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1183\/09031936.97.10010226","article-title":"Heart-lung interactions: applications in the critically ill","volume":"10","author":"Fessler","year":"1997","journal-title":"Eur Respir J"},{"key":"2026073121215118800_zuag099-B2","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCHEARTFAILURE.120.007099","article-title":"Invasive hemodynamic assessment and classification of in-hospital mortality risk among patients with cardiogenic shock","volume":"13","author":"Thayer","year":"2020","journal-title":"Circ Heart Fail"},{"key":"2026073121215118800_zuag099-B3","doi-asserted-by":"crossref","first-page":"728","DOI":"10.1007\/s00134-022-06698-x","article-title":"In search of the holy grail: identifying the best PEEP in ventilated patients","volume":"48","author":"Gattinoni","year":"2022","journal-title":"Intensive Care Med"},{"key":"2026073121215118800_zuag099-B4","first-page":"300","article-title":"Positive pressure ventilation in cardiogenic shock: review of the evidence and practical advice for patients with mechanical circulatory support","volume":"36","author":"Alviar","year":"2020","journal-title":"Can J Cardiol"},{"key":"2026073121215118800_zuag099-B5","doi-asserted-by":"crossref","first-page":"2412","DOI":"10.1002\/ejhf.3409","article-title":"Ventilation strategies in cardiogenic shock: insights from the AltShock-2 registry","volume":"26","author":"Sacco","year":"2024","journal-title":"Eur J Heart Fail"},{"key":"2026073121215118800_zuag099-B6","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1016\/j.jacc.2022.01.018","article-title":"SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies: this statement was endorsed by the American College of Cardiology (ACC), American College of Emergency Physicians (ACEP), American Heart Association (AHA), European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC), International Society for Heart and Lung Transplantation (ISHLT), Society of Critical Care Medicine (SCCM), and Society of Thoracic Surgeons (STS) in December 2021","volume":"79","author":"Naidu","year":"2022","journal-title":"J Am Coll Cardiol"},{"key":"2026073121215118800_zuag099-B7","doi-asserted-by":"crossref","first-page":"1113","DOI":"10.1161\/CIRCULATIONAHA.123.064527","article-title":"Standardized definitions for cardiogenic shock research and mechanical circulatory support devices: scientific expert panel from the shock academic research consortium (SHARC)","volume":"148","author":"Waksman","year":"2023","journal-title":"Circulation"},{"key":"2026073121215118800_zuag099-B8","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1186\/s13054-025-05459-8","article-title":"Driving pressure vs. Oxygenation-based PEEP titration strategies in ARDS patients: a physiological study","volume":"29","author":"Coppola","year":"2025  8","journal-title":"Crit Care"},{"key":"2026073121215118800_zuag099-B9","volume-title":"Mechanical Ventilation Manual","author":"Raoof","year":"1998"},{"key":"2026073121215118800_zuag099-B10","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s00134-023-07050-7","article-title":"ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies","volume":"49","author":"Grasselli","year":"2023","journal-title":"Intensive Care Med"},{"key":"2026073121215118800_zuag099-B11","doi-asserted-by":"crossref","first-page":"829","DOI":"10.1016\/j.cardfail.2024.01.018","article-title":"Guide to lung-protective ventilation in cardiac patients","volume":"30","author":"Rali","year":"2024","journal-title":"J Card 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