BACKGROUND: Previous studies indicate that avoiding neuromuscular blocking agents (NMBAs) may be a risk factor for difficult tracheal intubation (DTI). We investigated whether avoiding NMBA was associated with DTI. METHODS: A cohort of 103,812 consecutive patients planned for tracheal intubation by direct laryngoscopy was retrieved from the Danish Anaesthesia Database. We used an intubation score based upon the number of attempts, change from direct laryngoscopy to a more advanced technique, or intubation by a different operator. We retrieved data on age, sex, ASA physical status classification, priority of surgery, time of surgery, previous DTI, modified Mallampati score, BMI, and the use of NMBA. Using logistic regression, we assessed whether avoiding NMBA was associated with DTI. RESULTS: The frequency of DTI was 5.1 [95% confidence interval (CI): 5.0-5.3]%. In a univariate analysis, avoiding NMBA was associated with DTI, odds ratio (OR) 1.52 (95% CI: 1.43-1.61)%, P<0.0001. Using multivariate analysis, avoiding NMBA was associated with DTI, OR 1.48 (95% CI: 1.39-1.58), P<0.0001. Among patients intubated using NMBA, a multivariate analysis identified patients anaesthetized with only non-depolarizing NMBA to be more at risk for DTI than those anaesthetized with depolarizing NMBA alone. CONCLUSIONS: Avoiding NMBA may increase the risk of DTI. However, confounding by indication may be a problem in this observational study and systematic reviews with meta-analysis or more randomized clinical trials are needed.