Agonal breathing, also known as agonal respiration or gasping respiration, can occur when someone is experiencing a life-threatening medical emergency. In order to respond properly and give the victim the help they need, you’ll need to know how to recognize this type of gasping and also identify what’s causing it.
What Is Agonal Breathing?
The term “agonal breathing” is a bit of a misnomer. Agonal breathing isn’t actually breathing at all; it’s a brainstem reflex that stems from a lack of oxygen to the brain. The absence of oxygen leads to involuntary gasping that can occur whether or not the patient is conscious or breathing.
Without a healthy supply of oxygen-rich blood to the brain and other organs, the victim can die within minutes. That’s why it’s so important to take immediate action when agonal breathing occurs.
What Causes Agonal Breathing?
There are several possible causes for agonal breathing, the most common of which are cardiac arrest and ischemic stroke.
Cardiac Arrest: This is the single most common cause of agonal breathing. In fact, agonal breathing occurs in about 40% of out-of-hospital cardiac arrest cases[mfn]annemergmed.com[/mfn]. In a cardiac arrest incident, the heart stops beating due to an electrical malfunction. As a result, the heart can no longer pump oxygen-rich blood to the brain and other vital organs. Within minutes, those organs can shut down, resulting in death.
Ischemic Stroke: Also referred to as cerebral ischemia, this is the most common type of stroke, accounting for about 87% of all stroke cases[mfn]stroke.org[/mfn]. It’s caused by a lack of oxygen-rich blood to the brain, usually due to a blocked blood vessel.
Other, less common causes of agonal breathing include:
- Hemorrhagic stroke: the result of a bleeding blood vessel in the brain
- Drug overdose: often as a result of narcotic or opioid use
- Anoxia: a complete lack of oxygen in the body
How to Respond to Agonal Breathing
There is some good news. If the agonal respirations are caused by cardiac arrest (which they most often are), the patient has a greater chance of survival[mfn]annemergmed.com[/mfn] than they would if they simply lost consciousness and fell silent—but only if swift action is taken. So what can you do?
1. Determine That It’s Really Agonal Breathing
What does agonal breathing sound like? It usually sounds like painful gasping; in some cases, it resembles labored breathing, snorting, or even moaning. The reflex is often coupled with short, violent spasms or twitches. This type of respiration is sometimes referred to as fish breathing, as the victim looks like a struggling fish out of water.
If you think the problem might be agonal breathing, count the gasping breaths. In most cases, the gasps are not delivered in rapid succession. Agonal breaths are sporadic by nature, but most responders report these often-called ‘dying breaths’ at a rate less than 10-12 times per minute, as opposed to standard breathing rates of 12-20 breaths per minute.
In addition, don’t confuse agonal respirations with the so-called death rattle. The death rattle also occurs in a life-threatening emergency, but it’s not the same as agonal breathing. It’s more of a gurgling or congested breathing resulting from mucus build-up in a dying person’s chest. If the gasping sounds like a death rattle, simply call 911 immediately and wait with the patient.
2. Determine the Cause of the Agonal Breathing
Once you’ve confirmed that the patient is exhibiting agonal respirations, the next step is to determine why it’s happening. Knowing the underlying cause will help you to assess the best immediate course of treatment.
Almost every instance of agonal breathing will result from either cardiac arrest or stroke. Consider the signs of each:
| It May Be Cardiac Arrest If… | It May Be a Stroke If… |
| The victim is not breathing | The victim is breathing (though not always) |
| The heart is not beating | The heart is beating; beats may be irregular |
| The victim has no pulse | The victim has a pulse |
| The victim is unconscious and unresponsive | The victim is dizzy, confused, or disoriented |
| The victim was exhibiting chest pain or heart palpitations before collapsing | The victim’s body is weak on one or both sides |
| The victim looks otherwise normal | The victim’s face is drooping or numb |
Always start by gently shaking and shouting at the patient for a response. A stroke victim will usually be able to provide some type of response, even if it’s just incoherent mumbling or shaking their head. Stroke only leads to loss of consciousness in rare cases[mfn]academic.oup.com[/mfn], but cardiac arrest always leads to loss of consciousness. That’s going to be your biggest indicator. Look for the signs, and then act accordingly.
3. Provide the Appropriate Assistance
Once you know what you’re dealing with, the next step is to take action.
If the person is suffering from cardiac arrest:
- Call 911 immediately.
- Retrieve an automated external defibrillator (AED), if one is available.
- Turn on the AED and follow the step-by-step voice prompts.
- Perform CPR chest compressions while the AED assesses the patient’s heart (push down on the chest at a depth of 2 to 2.4 inches and a rate of 100 to 120 beats per minute; just use the beat of “Stayin’ Alive” to keep the appropriate pace).
- Press the “Shock” button on your AED if the device prompts you to do so.
- If the patient remains unconscious, continue CPR until emergency services arrive.
If you don’t have an AED available, just call 911 and perform CPR chest compressions until help arrives. For more information, refer to our guide on how to perform CPR.
If the person is having a stroke:
- Call 911 immediately.
- Note the exact time when symptoms first emerged, as this will indicate to medical personnel whether a tissue plasminogen activator can be used[mfn]pennmedicine.org[/mfn] to stop the damage.
- Perform CPR only if the individual is unconscious and not breathing. Most stroke sufferers won’t need CPR.
- Wait with the individual until emergency services arrive, and make sure they remain awake the entire time.
If you’re not sure why the patient is experiencing agonal breathing, or if you suspect that the cause may be something other than cardiac arrest or stroke, just call 911 and wait with the patient. If the patient isn’t breathing, perform CPR chest compressions until emergency services arrive.
Cardiac Arrest Preparedness Is Key
In a majority of cases, agonal breathing is a sign of cardiac arrest. So the best thing you can do is to buy an AED device. These defibrillators make it possible to provide immediate treatment to cardiac arrest patients and possibly even restart their heart before irreversible organ damage occurs.
Agonal breathing is scary, but it can also be to your advantage if you know how to spot it. It serves as a cry for help from individuals who otherwise can’t communicate their urgency to you. It gives you the opportunity to take action, seek help, and perhaps even save a life when every second counts.
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