What Do You Do If Someone Is Not Breathing but Has a Pulse?

When someone has a pulse but is not breathing, the response is rescue breathing without chest compressions. This is respiratory arrest, not cardiac arrest, and the distinction matters because the heart is still working on its own. Your job is to breathe for the person until they start breathing again or emergency medical services arrive. Untreated respiratory arrest can deteriorate into full cardiac arrest in as little as five minutes, so acting quickly is the difference between a recoverable emergency and a fatal one.

Confirming What You Are Dealing With

Before you start rescue breaths, you need to verify two things: the person is not breathing (or not breathing adequately), and they do have a pulse. Both checks are harder than most people assume, and getting either one wrong changes everything about what you should do next.

Checking for a pulse sounds straightforward, but even trained professionals get it wrong a surprising amount of the time. In one study using CPR training mannequins, lay persons achieved only about 63% accuracy on carotid pulse checks, compared with roughly 93% for trained lifesavers and paramedics. Lay persons also took much longer, averaging about 20 seconds versus 7 seconds for trained rescuers.¹ In pediatric settings, manual pulse palpation was found to be only about 78% accurate overall, with a low specificity that led healthcare workers to withhold needed compressions in 14% of cases and perform unnecessary compressions in 36% of cases.² The practical takeaway: if you are not confident you feel a pulse within ten seconds, current guidelines generally say to start CPR with compressions. A false negative on a pulse check is far less dangerous than standing by while someone’s heart has actually stopped.

Assessing breathing has its own pitfalls. You are looking for normal, effective breathing, not just any movement of the chest or any sound. One study found that when observers were shown abnormal breathing patterns, only about 61% correctly identified them as abnormal, and nearly 30% mistakenly called abnormal breathing “normal.”³ The biggest danger here is agonal breathing, which shows up in roughly 40% of out-of-hospital cardiac arrests. Agonal breaths are irregular gasps or grunting that can look like the person is still alive and breathing. They are not effective breaths, and they are commonly mistaken for signs of life, leading bystanders to hold off on resuscitation.⁴ If you see occasional gasps but no steady, rhythmic breathing, treat the person as not breathing.

Opening the Airway

Before you deliver any breaths, you need the airway to be clear. The most common reason an unconscious person cannot breathe adequately is that the tongue has fallen back and is blocking the throat. Two maneuvers fix this.

The standard approach is the head tilt-chin lift: tilt the person’s head back gently with one hand on the forehead while lifting the chin with your other hand. This shifts the tongue forward and opens the airway in most cases. However, if you suspect a neck or spinal injury, such as after a fall, car crash, or diving accident, the head tilt-chin lift can be dangerous. Studies on cadavers with unstable upper cervical spine injuries found that the head tilt-chin lift produced almost twice as much angular motion at the injury site as a jaw thrust.⁵ The jaw thrust is the safer alternative in suspected spinal trauma: you place your fingers behind the angles of the jaw on both sides and push the lower jaw forward without moving the head or neck.⁶

If you have no reason to suspect a spinal injury, use the head tilt-chin lift. It is easier to perform and more intuitive. The jaw thrust requires a bit more practice and hand strength, but in a potential neck injury it is clearly the better choice.

How to Give Rescue Breaths

Once the airway is open, pinch the person’s nose shut, seal your mouth over theirs, and blow in steadily for about one second per breath. You should see the chest rise. If the chest does not rise, reposition the head and try again: the airway is probably not open enough. Deliver one breath every five to six seconds, which works out to roughly 10 to 12 breaths per minute for an adult. For children and infants, American Heart Association guidelines recommend a similar pace of about one breath every six to eight seconds, or roughly 8 to 10 breaths per minute, when the child has a pulse but is not breathing.⁷

Every two minutes, briefly recheck the pulse. If the person still has a pulse, keep giving rescue breaths. If you lose the pulse, switch immediately to full CPR with chest compressions. This reassessment cycle is critical because respiratory arrest is a waypoint on the path to cardiac arrest, not a stable resting place.

Why Minutes Matter

The body follows a predictable sequence when oxygen stops reaching tissues. Research on patients approaching death found a consistent pattern: oxygen levels drop first, then blood pressure falls, and then the heart rate slows.⁸ The heart is remarkably resistant to hypoxia; it keeps pumping for a while even when oxygen levels plummet. But “a while” is not long. In hospital settings, unrecognized respiratory arrest due to medications has progressed to cardiac arrest, brain damage, or death in as little as five minutes.⁹

This is exactly why rescue breathing for someone with a pulse is so time-sensitive. You are intervening during the window where the heart is still working but the body is running out of oxygen. Every breath you deliver buys more time. The moment the heart gives out from oxygen starvation, the situation becomes dramatically harder to reverse.

Opioid Overdoses and Naloxone

One of the most common reasons a person stops breathing while their heart still beats is an opioid overdose. Opioids suppress the brainstem’s drive to breathe, sometimes to the point of complete arrest. This is treatable. Naloxone (often carried as Narcan nasal spray) can reverse the respiratory depression, and many states have made it available over the counter for exactly this reason.

If you suspect an opioid overdose, give naloxone if you have it, but do not wait for it to work before starting rescue breaths. Naloxone takes a few minutes to take effect, and its half-life is short, roughly 33 minutes, which can be much shorter than the opioid that caused the problem.¹⁰ This means the person can stop breathing again after the naloxone wears off. Rescue breaths bridge the gap between administering naloxone and its onset, and continuous monitoring afterward is essential because re-sedation is a real risk.

The combination of rescue breathing plus naloxone plus calling 911 is the gold standard response for witnessed opioid overdoses. Doing any one of these alone is better than doing nothing, but all three together give the person the best shot.

Drowning Is Different

Drowning-related respiratory arrest is another scenario where rescue breathing is indispensable. In most cardiac arrests that happen on dry land, the cause is a heart problem, and compression-only CPR (without mouth-to-mouth) has been shown to be roughly as effective as traditional CPR with breaths for bystanders.¹¹ But drowning is fundamentally different. The arrest happens because the person ran out of oxygen, not because their heart malfunctioned. You cannot fix an oxygen problem with compressions alone.

A consensus statement on drowning resuscitation put this bluntly: compression-only CPR significantly reduces survival in drowning because ventilation is essential to reverse the underlying cause.¹² If you pull someone from the water and they have a pulse but are not breathing, rescue breaths are the single most important thing you can do. If they have no pulse either, you perform full CPR, but the breaths matter even more than usual in this context. The same logic applies to any respiratory arrest caused by suffocation, choking (after the obstruction is cleared), or any situation where the core problem is that the person could not get air.

The Danger of Breathing Too Fast

One of the most common mistakes rescuers make, including professional ones, is breathing too fast for the patient. The instinct to blow more air more often feels like it should help. It does not. In animal studies, increasing the ventilation rate from 12 breaths per minute to 30 breaths per minute dramatically raised pressure inside the chest, cut blood flow to the heart, and dropped survival rates from about six out of seven animals down to one out of seven.¹³ Further research confirmed that excessive ventilation rates create an inversely proportional relationship between chest pressure and the blood flow the heart needs to keep working.¹⁴

Those studies were done in the context of CPR, where compressions are happening simultaneously, and the hemodynamic consequences of over-ventilation are most pronounced. But the lesson still applies to isolated rescue breathing: slow, steady, one-second breaths at the recommended rate. Blowing harder or faster does not get more oxygen in. It increases the risk of pushing air into the stomach (gastric insufflation), which can cause vomiting and aspiration, making the situation far worse. One breath every five to six seconds. Watch the chest rise. That is the tempo.

Barrier Devices and Why People Hesitate

A major reason bystanders avoid performing rescue breathing is the thought of putting their mouth on a stranger’s. Surveys have found that only about 15% of people said they would “definitely” provide mouth-to-mouth ventilation to a stranger, compared with 68% who would perform chest compressions. Even with friends or relatives, only about 74% were willing to do mouth-to-mouth, versus 88% for compressions alone. About 82% of respondents were at least moderately concerned about catching a disease.¹⁵

Pocket masks address this hesitation. They are small, inexpensive plastic devices with a one-way valve that sits between your mouth and the patient’s face. Research has found them feasible for single rescuers to use, with participants rating them easy or somewhat easy, and they do not create a meaningful technical barrier during resuscitation.¹⁶ Compared with simpler face shields (flat plastic barriers), pocket masks deliver more effective ventilations and cause shorter interruptions in any compressions being performed.¹⁷ While the volumes delivered through pocket masks tend to be somewhat less than direct mouth-to-mouth, several commercial devices deliver volumes large enough to serve as an effective substitute.¹⁸

If you work somewhere that has first-aid kits, check whether they include a pocket mask. If you are someone who carries a small personal emergency kit, a pocket mask is a worthwhile addition. Anything that makes you more willing to start rescue breathing is worth having, because the person who is not breathing cannot wait for you to sort through your feelings about mouth-to-mouth contact.

Rescue Breathing for People With a Stoma

People who have had a laryngectomy, a surgery that removes the voice box, breathe through a permanent opening (stoma) in the front of their neck rather than through their mouth and nose. Standard mouth-to-mouth ventilation will not work for them, because their upper airway is no longer connected to their lungs. Rescue breaths must be delivered through the stoma.

One practical approach studied in laryngectomy patients involved placing a standard tracheal tube with an inflated cuff over the outside of the stoma and ventilating through the tube. Researchers found that oxygen saturation, expired volumes, and carbon dioxide readings all stayed within acceptable limits using this method, and it was simple enough that a patient’s family members or carers could learn to do it with minimal training.¹⁹ If no tube is available, you can seal your mouth directly over the stoma and breathe into it, though this is less hygienic and less controlled. The key point is awareness: if you see a person with a stoma who is not breathing, look at their neck, not their face.

Why Rescue Breathing Gets Overlooked

Over the past two decades, public CPR education has increasingly emphasized “hands-only” or compression-only CPR. This shift happened for good reasons. Large trials found no significant difference in survival between compression-only CPR and traditional CPR with breaths when performed by bystanders for cardiac arrests in adults.¹¹ Simplifying the message to “push hard, push fast” removed the barrier of mouth-to-mouth contact and almost certainly got more bystanders to act in cardiac emergencies.

But this message has a blind spot. When the problem is purely respiratory, as in opioid overdoses, drowning, choking, or medication-induced respiratory depression, compressions alone are not enough. The heart is working fine; it just needs oxygenated blood to pump. You provide that through ventilation. The compression-only messaging works well for the most common bystander scenario (witnessed sudden cardiac arrest in an adult), but it does not cover the full range of emergencies. If someone is not breathing but has a pulse, they need air, not chest compressions.

An observational study on out-of-hospital cardiac arrest found that in unwitnessed cases, standard bystander CPR that included rescue breaths produced better outcomes than compression-only CPR.²⁰ This makes sense: when the cause of arrest is uncertain and might be respiratory, adding breaths covers more possibilities. The broader lesson is that “hands-only CPR” was never meant to be the universal answer; it was a simplification for the most common scenario. In any situation where hypoxia is the primary problem, ventilation remains essential.

Legal Protections for Bystanders

Fear of legal consequences occasionally stops people from helping. In the United States, Good Samaritan laws exist in every state to protect people who provide voluntary, good-faith emergency assistance. A clinical review of responding to motor vehicle collisions noted that these laws shield even physicians from legal liability when they perform volunteer assistance in the community, and the protections extend to non-medical bystanders as well.²¹ The specifics vary by state, but the general principle is consistent: if you act in good faith to help someone in a genuine emergency, you are protected. Doing nothing while someone suffocates in front of you is the option with the worst outcomes for everyone involved.