Phenotype-based modeling of postoperative ventilatory liberation failure: A dynamic mechanistic framework for precision perioperative medicine

Postoperative ventilatory liberation failure is usually recorded as a late binary event, although vulnerability often develops earlier through anesthesia, mechanical ventilation, neuromuscular blockade, analgesia, fluid therapy, surgical stress, and the transition to spontaneous breathing. This conceptual review proposes a phenotype-based framework that redefines postoperative liberation failure as a dynamic syndrome generated by four interacting dimensions: neuromuscular contractile insufficiency, effort-related diaphragmatic myotrauma, central respiratory-drive suppression, and cardiovascular load intolerance. Using conceptual framework analysis and a scoping-informed mapping strategy, the model links cumulative perioperative exposures to stage-specific vulnerability trajectories spanning readiness assessment, spontaneous-breathing-trial stress, and post-extubation sustainability. The framework is not a validated bedside algorithm, but a falsifiable mechanistic architecture for phenotype definition, prospective validation, mechanism-directed trials, and interpretable clinician-in-the-loop decision support.