Several taxonomically disparate groups of fishes have evolved the ability to extract oxygen from the air with elements of their gut. Despite perceived difficulties with balancing digestive and respiratory function, gut air breathing (GAB) has evolved multiple times in fishes and several GAB families are among the most successful fish families in terms of species numbers. When gut segments evolve into an air-breathing organ (ABO), there is generally a specialized region for exchange of gases where the gut wall has diminished, vascularization has increased, capillaries have penetrated into the luminal epithelium and surfactant is produced. This specialized region is generally separated from digestive portions of the gut by sphincters. GAB fishes tend to be facultative air breathers that use air breathing to supplement aquatic respiration in hypoxic waters. Some hindgut breathers may be continuous, but not obligate air breathers (obligate air breathers drown if denied access to air). Gut ABOs are generally used only for oxygen uptake; CO₂ elimination seems to occur via the gills and skin in all GAB fishes studied. Aerial ventilation in GAB fishes is driven primarily by oxygen partial pressure of the water (PO₂) and possibly also by metabolic demand. The effect of aerial ventilation on branchial ventilation and the cardiovascular system is complex and generalizations across taxa or ABO type are not currently possible. Blood from GAB fishes generally has a low blood oxygen partial pressure that half saturates haemoglobin (p50) with a very low erythrocytic nucleoside triphosphate concentration [NTP]. GAB behaviour in nature depends on the social and ecological context of the animal as well as on physiological factors.