We have read with great interest the recent article by Kheterpal et al., indicating that sugammadex may be associated with a lower incidence of postoperative pulmonary complications, compared with neostigmine, when used for reversal of neuromuscular blockade in adults.

With a comprehensive matching approach, Kheterpal et al. successfully balanced demographic, procedural, and intraoperative factors between groups. However, given the 5-yr study period and a median time difference of 29 months between the neostigmine and sugammadex groups, we contend that it is critical to include an examination of the trend of complications over time informed by the date of intervention, which could be achieved by an interrupted time series analysis.

Numerous studies have demonstrated substantial changes in postoperative pulmonary complication rates over time.2–4  Although the authors take steps to account for temporal bias, including matching...

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