In Reply

Thank you for providing an opportunity to respond to the interesting letters written by Drs. Cumberworth, Meyer and Eikermann, Austin and Lam, Caruso et al., and Zhang et al. In our study, “Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia,”¹  a small minority of patients (approximately 4%) had only a supraglottic airway device used during the case. Approximately 6% of patients included in our analysis were admitted postoperatively to the intensive care unit with an endotracheal tube in place. We did not formally adjust for these groups of patients in our analyses but agree that doing so may have strengthened our findings. Regardless of this potential improvement, based on our results, we agree with the sentiment that reversal of neuromuscular blocking agents should be both routine and guided by neuromuscular transmission monitoring (preferably quantitative). We appreciate that current national practices around neuromuscular monitoring are evolving and not uniform. National practice guidelines would help, as would additional refinements to the monitoring technology itself, given its immaturity. Our research group recently published an article outlining existing barriers and calling for the development of more robust, user-friendly neuromuscular monitoring technology.²  Finally, we appreciate the comment regarding residual confounding in our propensity analysis. Although not included in table 1 of our article (Patient Demographics and Clinical Characteristics before and after Matching),¹  the rates of smoking and chronic obstructive pulmonary disease were similar between groups. We appreciate very much the interest in our work and hope that our findings will help raise attention to the importance of developing strategies to reduce postoperative pneumonia.