Objective To systematically evaluate the effect of sugammadex and neostigmine on reversing neuromuscular block in patients with postoperative pulmonary complication (PPC) by Meta‑analysis and trial sequential analysis (TSA). Methods PubMed, Medline, Embase, Cochrane Library, CNKI, Wanfang Data, and Vipshop Databases were searched. Randomized controlled trial (RCT) comparing the effects of sugammadex and neostigmine on PPC were collected. The searches were all conducted from database creation to October 2022. Two researchers screened the literature according to the inclusion and exclusion criteria, evaluated the quality of the included literature, and extracted data for Meta‑analysis using RevMan 5.2 and Stata 15.1 software, and TSA software for analysis of outcome indicators. The funnel plot and Egger test were used to analyze the publication bias of the literature, the impact of publication bias on the results was assessed by the cut‑and‑patch method, and the reliability of the combined effect values was determined by a sensitivity analysis using the one‑by‑one exclusion method. Results A total of 13 RCT studies were included, and the overall quality of the literature was good. Meta‑analysis showed that reversal of neuromuscular blockade with sugammadex significantly reduced the incidence of PPC compared with neostigmine [odds ratio (OR) 0.55 [95% confidence interval (CI) 0.39, 0.75], P<0.001].Stratified analysis according to the risk of PPC showed a higher incidence of PPC in the high‑risk group (31.12% sugammadex and 41.38% neostigmine) and a lower incidence in the other groups (3.53% sugammadex and 8.88% neostigmine). There was low heterogeneity between the groups (I2=0). The effect size within the group showed statistical significance [OR 0.60 (95% CI 0.41, 0.88), P=0.008, I2=0] in the high‑risk group; [OR 0.42 (95% CI 0.22, 0.78), P=0.006, I2=0] in the other groups. TSA analysis of outcome measures showed that the sample size of outcome measures for pulmonary complications (1 429) exceeded the expected amount of information (1 343). TSA cumulative Z curves exceeded TSA boundaries and the results were truly positive. Funnel plots showed asymmetric distribution across studies, and Egger's test also suggested publication bias (P<0.05). The results of the scissors supplement method showed that there was no significant change in the difference, suggesting that publication bias did not affect the stability of the results. Sensitivity analysis showed little change in the combined results. Conclusion Compared with neostigmine, reversal of neuromuscular block with sugammadex is effective in reducing the incidence of PPC.