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Farag, E., Shah, K., Argalious, M., et al. | Br J Anaesth (2025) 135(1):197-205 | Pulmonary complications associated with sugammadex or neostigmine in patients recovering from advanced diagnostic or interventional bronchoscopy: a retrospective two-centre analysis

November 29, 2025

Background: Many diagnostic and interventional procedures are performed in bronchoscopy suites in high-risk patients. Minor impairment in respiratory muscle function caused by incomplete reversal of neuromuscular block can contribute to postoperative pulmonary complications (PPCs). This study assessed whether serious PPCs are less frequent after diagnostic or therapeutic bronchoscopy when neuromuscular block is reversed with sugammadex rather than neostigmine.

Methods: This retrospective cohort study included patients undergoing bronchoscopy under general anesthesia with neuromuscular blockers between July 2016 and June 2022. The primary outcome was a composite of postoperative pulmonary complications. The secondary outcome was hypoxemia. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding, and weighted outcome regression models were applied to evaluate the association between reversal agent and outcomes.

Results: A total of 8,557 bronchoscopies performed in 6,123 patients were included in the primary analysis. Adequate balance across potential confounders was achieved after IPTW. The unweighted incidence of PPCs was 2.2% (85/3,830) in the sugammadex group and 2.0% (93/4,727) in the neostigmine group. After weighting, the incidence of PPCs was 2.7% with sugammadex and 1.9% with neostigmine. Sugammadex was associated with higher odds of postoperative pulmonary complications (odds ratio 1.44; 95% confidence interval 1.02-2.05; P = 0.038), but not with hypoxemia (odds ratio 0.98; 95% confidence interval 0.81-1.20; P = 0.878).

Conclusions: Sugammadex was associated with a higher risk of postoperative pulmonary complications than neostigmine following bronchoscopy. However, the absolute increase in risk (0.8%) was small and may not be clinically meaningful. Randomized clinical trials are needed to more accurately determine the effect of neuromuscular block reversal agent selection on respiratory complications.

Keywords: bronchoscopy; interventional pulmonology; neostigmine; neuromuscular block; postoperative pulmonary complications; sugammadex.