Sugammadex Linked to Lower Pneumonia in COPD Surgery Cohort
Key Takeaways
- In adults with COPD undergoing elective gastrointestinal, urological, or orthopedic surgery under general anesthesia, sugammadex was associated with less postoperative pneumonia during the first 30 days than neostigmine.
- Thirty-day COPD exacerbations and all-cause mortality were not significantly different between the matched reversal groups.
- ICU admission was more frequent with sugammadex in the primary matched analysis.
- The early pneumonia association was not maintained during 30 to 90 days of follow-up.
- Sensitivity and subgroup analyses suggested a stronger pneumonia association in academic centers and in adults older than 65 years.
In a retrospective cohort study using the matched TriNetX COPD surgery cohort in Medicine, investigators identified adults 18 years or older with documented COPD who underwent elective gastrointestinal, urological, or orthopedic surgery under general anesthesia between 2015 and 2024. They compared rocuronium followed by sugammadex reversal with rocuronium followed by neostigmine reversal, excluded patients with stage 4 or 5 chronic kidney disease, dialysis, or recent acute kidney injury, respiratory failure, intensive care unit (ICU) admission, or COVID-19, and used 1:1 greedy nearest-neighbor propensity score matching with a caliper of 0.1 standard deviations of the logit of the propensity score. Matching incorporated age, sex, race, body mass index, comorbidities, prior COPD exacerbation, and inhaled corticosteroid use and produced 34,031 patients in each cohort.
Within 30 days after surgery, postoperative pneumonia occurred in 1.8% of the sugammadex group and 2.1% of the neostigmine group (hazard ratio
0.84, 95% confidence interval [CI] 0.75–0.94; P=.002). ICU admission over the same interval was 2.3% versus 1.9% (HR 1.22, 95% CI 1.10–1.36; P<.001). COPD exacerbation and all-cause mortality were not significantly different between groups during the first postoperative month.
That pneumonia association was not sustained during days 30 to 90, when rates were 1.5% in each group (HR 0.99, 95% CI 0.87–1.12; P=.816). In the academic-medical-center sensitivity analysis, pneumonia was 1.9% with sugammadex and 2.9% with neostigmine (HR 0.64, 95% CI 0.57–0.73; P<.001). Subgroup analyses suggested the pneumonia association was present in both sexes and appeared stronger in adults older than 65 years; a female mortality signal and a younger-adult COPD exacerbation association were also reported.
Because the comparison was retrospective and observational, the findings do not establish causality, and residual confounding may persist despite matching. Pneumonia ascertainment relied on diagnostic codes, while intraoperative factors such as depth of blockade, timing of reversal, and ventilation strategy were unavailable; COPD severity also could not be fully staged because spirometric confirmation was unavailable. The network was drawn predominantly from U.S.-based healthcare organizations, so portability to other perioperative settings may be limited. The authors suggested the ICU admission signal may reflect selection or institutional factors rather than a demonstrated adverse effect.
The authors concluded that sugammadex was associated with a modest reduction in short-term postoperative pneumonia compared with neostigmine in matched COPD surgical patients. That association was not accompanied by lower 30-day COPD exacerbation or mortality and did not persist beyond the immediate postoperative window.
Clinician Questions
How was COPD severity handled in the matched comparison of sugammadex and neostigmine?
Investigators used 1:1 propensity score matching and included prior COPD exacerbation history and inhaled corticosteroid use as matching variables, with standardized mean differences below 0.1 after matching across measured variables. Those steps balanced recorded severity proxies, but they did not replace spirometric confirmation or formal COPD staging.
Did age or sex change the sugammadex signal in COPD patients after elective surgery?
Subgroup analyses suggested the pneumonia association was present in both male and female patients, appeared strongest in adults older than 65 years, and was not evident in younger adults for pneumonia. The same analyses also reported a COPD exacerbation association in younger adults and a higher mortality hazard among women, and these should be interpreted as subgroup observations rather than causal effects.
Which perioperative factors were not captured in the TriNetX analysis of sugammadex versus neostigmine?
The dataset did not capture intraoperative depth of neuromuscular blockade, timing of reversal, or ventilation strategy, and COPD severity was incompletely characterized because spirometric confirmation and staging were unavailable. Postoperative pneumonia identification also relied on diagnostic codes, which could miss milder or uncoded events.
Why might ICU admission have been higher with sugammadex in the main COPD cohort?
The authors suggested that preferential use of sugammadex in patients perceived as higher risk, together with institutional differences in perioperative management, could explain the ICU signal. They also noted that the academic-medical-center sensitivity analysis did not reproduce a significant ICU difference, supporting interpretation of the finding as a possible selection effect rather than direct harm.