Should anesthesiologists have to confirm effective facemask ventilation before administering the muscle relaxant?

There is ongoing controversy as to whether effective facemask ventilation (FMV) should be established following induction of anesthesia before a muscle relaxant is administered. The rationale for such practice is the belief that, should FMV be ineffective, non-paralyzed patients can be woken up, and subsequently an alternative airway management can be considered. However, the chances of successfully restoring adequate spontaneous respiration before severe hypoxemia develops in an anesthetized, apneic patient who is prone to anesthetic-induced respiratory depression and airway collapse are very small. On the other hand, the overall evidence shows that muscle relaxation is likely to improve or leave unchanged, but not to worsen, the quality of FMV. Furthermore, muscle relaxation will facilitate placement of a supraglottic airway device and endotracheal intubation, interventions which may become essential should the patient become hypoxemic during failed FMV. Thus, the earliest administration of a muscle relaxant following induction of anesthesia may well be the most effective and safest practice. Insistence on demonstration of adequate FMV before administration of a muscle relaxant is more of a ritual than an evidence-based practice. It should therefore be abandoned.