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n this issue of Anesthesia & Analgesia, Oschatz et al. (1) report that when lay bystanders in Vienna, Aus- tria performed mouth-to-mouth ventilation in car- diac arrest victims before professional paramedics ad- ministered advanced cardiac life support, serious ventilation-related adverse effects such as pulmonary aspiration occurred no more often than in patients who collapsed in the presence of professional para- medics, and who therefore received advanced cardiac life support only. Without a doubt, the two most in- teresting questions raised by this article are the fol- lowing: why did lay bystander mouth-to-mouth ven- tilation not increase the ~15% rate of stomach inflation? And why did professional paramedics not achieve a rate of stomach inflation less than ~15%? When the airway is unprotected, the distribution of ventilation volume between lungs and stomach de- pends mainly on variables such as lower esophageal sphincter pressure (2), airway resistance, and respira- tory system compliance (3). Of equal importance are differences in technique applied while performing ba- sic or advanced airway support, such as head position, tidal volume, inflation flow rate, and duration, all of which determine upper airway pressure (4). The com- bination of these variables determines gas distribution between the lungs and the esophagus and, subse- quently, the stomach. There are several fundamental differences between these components of respiratory mechanics in a healthy, awake adult, an anesthetized supine patient, and a victim of cardiac arrest (Table 1). On the basis of these measurements, we evaluated simulated basic life support ventilation in both bench models and apneic patients and found that even ex- perienced paramedics and anesthesiologists can cause stomach inflation when performing routine bag-valve- mask ventilation (5,6). Moreover, we found that mouth-to-mouth ventilation skills in first-year medical students (who may be somewhat comparable to lay bystanders) deteriorated within 6 mo to levels that did not ensure proper basic life support ventilation per-

Mouth-to-Mouth Ventilation During Cardiopulmonary Resuscitation: Word of Mouth in the Street Versus Science