Mechanical ventilation in patients with cardiac failure presents several challenges for the medical professional. Dynamic changes in right and left ventricular preload and afterload occur during both induction for intubation and invasive positive pressure ventilation, increasing the risk of worsening shock and potential circulatory collapse. The type and degree of heart failure may also vary between patients requiring invasive respiratory support, layering even further complexity on the decision to intubate. Despite these concerns, invasive mechanical ventilation can be a lifesaving intervention for patients in cardiogenic shock or respiratory failure refractory to non-invasive methods. Considerations regarding the initiation, maintenance, and weaning from invasive mechanical ventilation are discussed here.