To the Editor:
I read with interest the recent article by Bulka et al.,1 which highlighted the association between perioperative use of neuromuscular blocking drugs and risk of postoperative pneumonia. It would have been useful to know which airway devices were used for the patients studied, because endotracheal intubation itself is known to be a risk factor for postoperative pneumonia and could therefore be a confounding factor. Of course, in the majority of cases, neuromuscular blockade is a prerequisite for endotracheal intubation, but not infrequently in the United Kingdom neuromuscular blockade is used in combination with a supraglottic airway device; this is generally restricted to cases where muscle relaxation is required to facilitate surgery and there is no requirement for a definitive airway. It would be telling if the strong association between the use of neuromuscular blocking drugs and postoperative pneumonia persisted irrespective of whether the trachea was intubated.
The author declares no competing interests.