We thank Li et al. for their interest and constructive feedback of the sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (STRONGER) study. We concur with them that temporal trends and “natural improvement in clinical practice may account for some of the reduction in complications.”

Although Li et al. cite previous work demonstrating major changes in intraoperative ventilation strategies over time, evidence of any recent, sustained improvement in pulmonary outcomes after noncardiac surgery is limited. Wanderer et al. and Schaefer et al., cited by Li et al., did not report pulmonary outcomes at all, simply intraoperative ventilator settings such as tidal volumes and positive end-expiratory pressure. Memtsoudis et al., also cited by Li et al., focused on lung surgery patients between...

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