Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid". According to WHO, drowning claim the lives of more than 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that more than 90% are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of O2 in different proportions. The combined effects of fluid in the lungs, loss of surfactant and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a non-cardiogenic pulmonary edema. Salt and fresh water aspiration cause similar pathology. If the person is not rescued, aspiration continues and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider patient´s drowning severity and co-or-premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt of 20% or less, or PaO2:FiO2 of 250 or more. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation, and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essentials steps from the first call to action until the best practice at the pre-hospital, emergency department, and hospitalization.