Postextubation Respiratory Muscle Recovery After Sugammadex or Neostigmine: A Randomized Controlled Ultrasonographic Trial in Laparoscopic Cholecystectomy

Background Sugammadex minimizes the residual neuromuscular block risk. By enhancing the function of expiratory muscles, it improves the clearance of secretions and helps prevent lung collapse, leading to a reduction in early postoperative respiratory issues. The study aims to compare the efficacy of sugammadex in promoting the recovery of expiratory muscle power to that of neostigmine following extubation. Study Objectives The main objective of this study was to evaluate the effectiveness of sugammadex and neostigmine as a reversal of neuromuscular block, assessed through ultrasonographic evaluation of expiratory muscle strength, specifically the thickening fraction of the internal oblique muscle (TFIO). The secondary objective was to assess diaphragmatic excursion (DE) and to explore the usefulness of ultrasonography in comparison to train‐of‐four (TOF) monitoring. Patients and Methods The study involved a total of 60 patients who underwent laparoscopic cholecystectomy between August 2023 and September 2024. Patients were randomly assessed into two groups for a comparative study. Group A received sugammadex, while Group B received neostigmine. The study utilized ultrasonography to measure the TFIO, reflecting expiratory muscle power, and DE, representing inspiratory muscle strength. Measurements were taken at three points in time: preinduction (baseline), at the TOF ratio recovery (TOFR) to 0.9, and 30 minutes postarrival in the postanesthesia care unit (PACU). The primary outcome was the variation in TFIO from baseline to a TOFR of ≥ 0.9. Secondary outcomes included the postoperative variation in DE from baseline, the incidence of recovery to baseline TFIO and DE, and the time taken for TOFR recovery to 0.95 and 1. Results A significant difference in the primary outcome was observed among 60 patients. The alteration in TFIO from baseline to TOFR ≥ 0.9 was markedly reduced with sugammadex relative to neostigmine (mean ± SD: 9.13 ± 6.25 vs. 19.32 ± 5.75; adjusted p < 0.001). Sugammadex resulted in a significantly smaller reduction in DE from initial values to TOFR ≥ 0.9 compared to neostigmine (right side: 1.91 ± 0.66 vs. 2.34 ± 0.52; adjusted p < 0.05). Thirty minutes post‐PACU arrival, a greater percentage of patients in the sugammadex group reached baseline TFIO in comparison to the neostigmine group (67% vs. 47%); even so, the difference was not of statistical significance (corrected p value = 0.118). The rate of TFIO and DE returning to initial values remained low for both groups, even after TOFR reached 1. The sugammadex group exhibited a significantly accelerated recovery of neuromuscular function. The median recovery time for the TOFR from 0.9 to 0.95 was 0.32 min, compared to 1.74 min with neostigmine (corrected p < 0.001). The median recovery time from 0.9 to 1.0 was 0.53 min, compared to 5.13 min (corrected p < 0.001). The neostigmine group exhibited a higher incidence of postoperative complications, including atelectasis (16.7% vs. 10%), hypoxia (16.7% vs. 6.7%), tachycardia (40% vs. 0%), PONV (16.7% vs. 10%), recurarization (3.3% vs. 0%), and other adverse drug effects (10% vs. 6.6%). No cases of reintubation, airway obstruction, pulmonary edema, or postoperative residual paralysis were observed in either group. Conclusion Sugammadex results in better expiratory muscle power recovery compared to neostigmine at TOFR of ≥ 0.9. These findings highlight that respiratory muscle function may remain compromised, although a TOFR of 1.0 is achieved. Trial Registration: ClinicalTrials.gov identifier: NCT06432621