(Psi)SeveredHead
Adventurer
Death saves? After X minutes, or immediately if you take certain actions?
The trouble is that in reality, nearly drowning doesn't cause injury or really fatigue you much in the long haul. I can dive underwater and hold my breath for a minute-ish, then pop up, get fresh air, and try it again after a minute. If you held me down and I had to flail to get to the surface a few seconds after I started to run out of air, I'd be short of breath and probably wouldn't want to go under again for a few minutes, but I'd be able to.
So breath shouldn't use healing surges or hit points.
When deprived of food, water, or air, the rule of three applies. An adventurer can handle three weeks without food, three days without water, and three minutes without air outside of strenuous situations.
I don't know if this is any good, and it involves action denial conditions which players justifiably hate, but my thought was to take RangerWickett's idea, and change the consequences of failing an Endurance check so it kind of resembles the Sleep spell. The player is dazed and makes a save at the end of his next turn. If the player fails the save, he is unconscious and dying. If he makes the save, he is still dazed and has to continue to make saves, until he's able to take a breath.
The unconscious/dying condition doesn't drop you to 0 hp or entail any HP loss. Players who are rendered unconscious underwater can't be returned to consciousness by methods that would normally do so if they can't breathe, but are stabilized by them. Even if a player that was rendered unconscious from lack of air is stabilized, he will still die if he is not revived within 3 minutes.
Maybe this is too cute, but I would also also consider a rule where a player can Second Wind to recover from the dazed from drowning condition and reset the Endurance check DC to 20.