The Slope Detector Does Not Always Detect The Presence Of Mouth

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The Slope Detector Does Not Always Detect The Presence Of Mouth Powered By Docstoc
B Y M I C H A E L P. H L A S T A L A , P H . D .
WAY N E J E L A M M , M . A A N D

The Slope Detector                            The first purpose of the slope detector is
Does Not Always                               to follow the exhaled BrAC until a flat
                                              exhalation profile is achieved indicating
Detect The Presence Of                        the presence of alveolar air to insure that
Mouth Alcohol                                 an adequate alveolar sample is obtained.
                                              However, because of the continual inter-
     The alcohol breath test is an indirect   action of alcohol with the airway
means of estimating the blood alcohol         mucosa during exhalation, it is impossi-
concentration (BAC). The most impor-          ble to get a sample of alveolar air to the
tant assumption is that after a prolonged     mouth without the alcohol concentra-
exhalation, the end-exhaled breath alco-      tion changing. The flat slope at the end
hol concentration (BrAC) accurately           of exhalation occurs simply because the
reflects the alveolar air, and hence, BAC.    subject has stopped exhaling. Further
Implicit in that assumption is that no        details regarding this mechanism have
alcohol has been added to the breath as       been described in a prior publication.1
it passes from the lungs to the breath-       In short, a flat plateau simply means that
testing unit (BTU). However, if there is      the subject has stopped exhalation. The
alcohol in the oral cavity or pharynx, it     flat slope does not mean that alveolar air
will vaporize during exhalation and add       has been obtained. So the first intended
to the BrAC. The functions of the slope       purpose of the slope detector does not
detector have been designed with the          work.
goal of ensuring that a valid alveolar air          The second intended feature of the
sample is obtained.                           slope detector, is to determine when
     Exhaled breath is monitored during       mouth alcohol is contributing to the
the exhalation to obtain a suitable breath    BrAC by identifying a negative slope (a       such conditions, the slope detector may
sample. Under normal circumstances,           decrease in BrAC as the exhalation pro-       not detect a decreasing exhalation pro-
BrAC increases during exhalation. The         ceeds). However, there are conditions         file and may not detect the additive
original developers of the breath test        when the increasing BrAC exhalation
reasoned that the BrAC rise would con-        profile superimposes on the decreasing
tinue until the alveolar air was obtained,    mouth alcohol exhalation profile result-                 Study Results
at which point the BrAC would level off.      ing in a flat exhalation profile. Under        Infrared absorption alcohol breath
                                                                                             test instruments use a “slope detec-
                                                                                             tor” that serves two primary func-
                                                                                             tions: the first is to identify “alveolar
                                                                                             air” from a flat breath alcohol con-
                                                                                             centration (BrAC) exhalation profile;
                                                                                             the second is to identify the pres-
                                                                                             ence of “mouth alcohol” as a
                                                                                             decreasing BrAC profile. Because of
                                                                                             the normal physiological properties
                                                                                             of the lungs, neither of these pur-
                                                                                             poses is accomplished by the slope
                                                                                             detectors as designed for breath test
                                                                                             units (BTU) used in law enforcement.
                                                                                             This study was undertaken to test
                                                                                             the hypothesis that the second pur-
                                                                                             pose of the slope detector does not
                                                                                             work when alcohol is present in the
                                                                                             blood stream as well as the mouth.
                                                                                             The data show that the slope detec-
 Figure 1. Exhaled alcohol profile from normal subject (modified from 9). Breath             tor does not adequately distinguish
 alcohol concentration (BrAC) normalized by alveolar alcohol concentration (Alv              mouth alcohol when alcohol is pres-
 AC) vs. exhaled volume in liters. Continued exhalation results in an increasing             ent in both the mouth and the blood
 BrAC. The BrAC depends on the exhaled volume.                                               stream.

W W W. N A C D L . O R G                                                                                    MARCH 2006                   57
      effect of mouth alcohol.                     the difference in temperature between         and slope detectors. Normal human vol-
            During inspiration, air is heated      the outside air and the alveolar air.11       unteers (n = 8) consumed alcohol until
      and humidified as it passes through the           The operation of a slope detector is     reaching a BrAC of approximately 0.10
      upper airways .2,3 Some water within the     confirmed by operators swishing or gar-       gm/210 L. The subjects were tested with
      mucous layer or watery sub-mucous            gling some mouthwash (containing              either a DM or an INT regularly to fol-
      layer will vaporize and heat stored in       alcohol) around the mouth and spitting        low the BAC profile. After the post-
      the airways will be picked up by the         the mouthwash out. There is no alcohol        absorptive phase was seen on 4 consecu-
      inspired gas and taken to the alveoli.       in the blood at the time of testing. This     tive breath tests (declining values after a
            During exhalation, the process         situation results in an increasing alcohol    peak of absorption), the subjects were
      reverses; fully humidified air at core       concentration during exhalation fol-          asked to swish a small amount (< 0.25
      body temperature is cooled by the cool-      lowed by a decreasing alcohol concen-         oz) of 80 proof liquor around in their
      er airway mucosa and water vapor con-        tration. The decreasing BrAC is identi-       mouth (over a 4-5 second period) and
      denses onto the mucosa.4 This water          fied as a negative slope and triggers an      spit out the contents. Breath alcohol
      and heat exchange process is vital           “Invalid” sample indication.12 However,       tests were then performed at regular
      because it conditions the inspired air to    in subjects having alcohol in their blood     intervals (approximately 2 – 3 minutes).
      avoid damaging the delicate alveolar         stream, the slope depends on the bal-              The detector voltage, which is pro-
      cells while conserving water and heat        ance between the rising lung alcohol and      portional to the measured ethanol con-
      from major loss in the exhaled air.          the decreasing mouth alcohol, which           centration from the BAC DataMaster 13
      Under normal environmental condi-            can result in a level (or slightly decreas-   (National Patent Analytical Systems,
      tions, exhaled gas has less heat and less    ing) slope and an inability of the slope      Inc., Mansfield, Ohio) was measured.
      water vapor than does alveolar air.5         detector to identify the added mouth          The detector voltage signal for alcohol
            The dynamics of soluble gas            alcohol. Only when the mouth alcohol          concentration was converted to g/210L
      exchange are similar to the dynamics of      curve has a large negative slope (< -         by analyzing the signal during the stan-
      heat and water exchange. These process-      0.006 gm/210 Liter for three consecutive      dard simulator test. Expired lung volume
      es are analyzed using similar equations.     data points with a DataMaster), will the      was measured with a digital spirometer
      The fact that respired air exchanges heat    slope detector then detect the mouth          (KORR, Medical Technologies Research
      and water with the airways implies sim-      alcohol and the reading will register as      Spirometry System, Salt Lake City, Utah)
      ilar alcohol exchange processes.6,7 The      an “invalid sample.”                          placed inline with the breath tube of the
      degree of interaction is directly related         This study was carried out to deter-     BAC DataMaster. Both the EtOH signal
      to the solubility of the gas in the airway   mine the conditions under which the           and expired volume signal were recorded
      mucosa and mucous lining. The very           slope detector is able (or unable) to         at 10 Hz with PowerLab (A-D
      high solubility of alcohol in water guar-    detect mouth alcohol in human subjects        Instruments, Colorado Springs, CO) on

      antees its strong interaction with airway    when the BAC is elevated.                     a PowerPC.
      tissue.8 Because this interaction depends
      on temperature and airflow characteris-      Materials And Methods                         Results
      tics, variations in tidal volume and fre-        We used two commercially avail-                In most (but not all) cases, the
      quency can have a substantial effect on      able BTUs: BAC Verifier DataMaster            swishing of alcohol immediately leads to
      the alcohol concentration in the breath      (DM) and Intoxilyzer 5000 (INT). Both         an invalid sample (indicative of a nega-
      sample.9,10 This variation is affected by    have similar alcohol detection systems        tive slope and the detection of mouth
                                                                                                 alcohol), sometimes followed by anoth-
                                                                                                 er invalid sample. After two or three
                                                                                                 tests, valid samples were obtained that
                                                                                                 exceeded the BrAC prior to the swish-
                                                                                                 ing. Figures 3 and 4 show consecutive
                                                                                                 breath tests from one subject after the
                                                                                                 subject swished alcohol in his/her
                                                                                                 mouth. In Figure 3, the initial breath test
                                                                                                 was an “invalid” sample, followed three
                                                                                                 minutes later by a valid test (BrAC =
                                                                                                 0.113 gm/210 L). After an additional 6
                                                                                                 minutes, a valid breath test of 0.042
                                                                                                 gm/210 L was obtained. This last test
                                                                                                 was presumably close to the blood alco-
                                                                                                 hol because it was similar to the BrAC
                                                                                                 prior to mouth alcohol and decreased
                                                                                                 slowly (at the approximate normal
                                                                                                 burn-off rate.
                                                                                                      In the second sequence of tests
                                                                                                 (Figure 4), the first “invalid” test was
       FIGURE 2. Exhaled breath alcohol profiles.The lower curve is obtained with alco-          obtained at 3:10 pm after consumption
       hol dissolved in the mouth with no alcohol in the blood. The middle curve is              of three additional one-once shots of
       obtained with alcohol in the blood with no alcohol in the mouth.The top curve             86-proof scotch. If the subject had
       is the sum of the two other curves obtained with alcohol in the blood and alco-           stopped exhalation at approximately
       hol dissolved in the oral mucosa (modified from (17)).                                    1.75 liters exhaled, the reading would
                                                                                                 have been a valid ë 0.31 gm/210 L. Three

58    W W W. N A C D L . O R G                                                                               THE CHAMPION
                                                                                         baseline 0.064. On average the first valid
                                                                                         sample read 0.098 Å 0.071 gm/210 L
                                                                                         (mean Å SD) greater than the baseline.
                                                                                         The valid breath samples did not return
                                                                                         to the baseline until 15 minutes had

                                                                                              Using normal procedures for testing
                                                                                         the slope detector, the operator will
                                                                                         swish some mouthwash (with alcohol)
                                                                                         and then exhale into the breath test
                                                                                         machine. These operators do not have
                                                                                         alcohol in their blood stream. Under
                                                                                         these conditions, exhaled BrAC will
                                                                                         increase to a maximum and then
                                                                                         decrease resulting in an “invalid sample.”
                                                                                              In a limited study using only three
                                                                                         subjects, Evans showed that a positive
                                                                                         BrAC test can be obtained in subjects
  Figure 3. Several exhalation profiles for breath alcohol tests taken at intervals      with no blood alcohol within 10 min-
  after sipping of 80 proof alcohol. An invalid sample is followed by two valid          utes of taking in mouth alcohol. This
  breath tests: one influence by mouth alcohol without mouth alcohol being               author did not study subjects with alco-
  detected.                                                                              hol in their blood stream. Wigmore14
                                                                                         studied nine female and twenty-one
                                                                                         male alcohol-free subjects after intro-
minutes later, the DM read a valid read-      had stabilized (indicating alcohol         ducing 10 ml of diluted alcohol (20%
ing with BrAC = 0.149. An additional 4        absorption has been completed), each       v/v alcohol) into their mouths. The sub-
minutes wait yielded a breath sample of       subject swished approximately 0.1 oz of    jects either rinsed the alcohol for 10 s
0.089. After an additional 9 minutes, the     alcohol and then took breath samples at    and then expectorated or immediately
BrAC was 0.076, the likely correct breath     two-minute intervals. In all cases there   swallowed. Each subject then provided
sample, as it was approximately the same      were valid breath samples that exceeded    breath samples into an Intoxilyzer 5000

as the BrAC was prior to the mouth alco-      the pre-mouth-alcohol BrAC. In all cases   at 5 and 10 min post-administration for
hol tests.                                    but one the test following the mouth       both conditions. They found valid posi-
     Further results from the other six       alcohol was an invalid sample. In the      tive tests in 28 out of 120 tests. They
subjects: three tested with the Intoxilyzer   first subject using the DataMaster, the    found that the mouth alcohol effect was
and three tested with the DataMaster are      first sample registered a valid 0.164,     greater for rinsing than for swallowing
shown in Table 1. After the BrAC tests        which was markedly greater than the        alcohol. This study is interesting in that
                                                                                         the subjects had only minimal blood
                                                                                         alcohol levels.
                                                                                              Gastroesophageal reflux disease
                                                                                         (GERD) is a condition that may cause
                                                                                         mouth alcohol due to the reverse flux of
                                                                                         stomach contents into the nasopharynx
                                                                                         resulting in the possibility of mouth
                                                                                         alcohol. Kachagias15 studied 5 female
                                                                                         and 5 male subjects with GERD asking
                                                                                         whether elevated breath alcohol tests
                                                                                         might result. Two of the four individual
                                                                                         subject data shown indicated the possi-
                                                                                         bility of an elevated BrAC. The authors
                                                                                         concluded: “the risk of alcohol erupting
                                                                                         from the stomach into the mouth owing
                                                                                         to gastric reflux and falsely increasing
                                                                                         the result of an evidential breath alcohol
                                                                                         test is highly improbable. However,
                                                                                         these authors studied only a very limit-
                                                                                         ed number of subjects leaving open the
                                                                                         possibility that GERD may play a role in
                                                                                         other subjects. In a related study,
 Figure 4. Several exhalation profiles for breath alcohol tests taken at intervals       Staubus16 showed that burping with
 after consuming three one-ounce shots of 86 proof scotch. An invalid sample is          alcohol in the stomach provided a false-
 followed by a three valid breath tests: the first two are influenced by mouth           ly high BrAC of up to 0.046 g/210 L.
 alcohol without an indication of mouth alcohol detection.                                    Generally, it is thought that mouth
                                                                                         alcohol will be rinsed away by saliva

W W W. N A C D L . O R G                                                                                 MARCH 2006                   59
                                                                                                                       inhalers were eliminated with a 15
                                                                                                                       minute observation period and hence,
                                                                                                                       asthma inhalers will not contribute to
                                                                                                                       mouth alcohol if taken more than 15
                                                                                                                       minutes before a breath test.
                                                                                                                             Because of the inadequacies of the
                                                                                                                       slope detector, extra precaution must be
                                                                                                                       used to be certain that mouth alcohol is
                                                                                                                       not contributing to a breath test. The
                                                                                                                       practice in many states is to perform two
                                                                                                                       breath tests within a short time (2-5
                                                                                                                       minutes). If the two breath tests are
                                                                                                                       identical to each other in magnitude,
                                                                                                                       then it is unlikely that mouth alcohol is
                                                                                                                             Some states take only one breath
                                                                                                                       test. This is dangerous because the role
        Table 1. Erroneously high, valid BrAC after mouth alcohol.Tests were performed                                 of mouth alcohol would be over-
        at approximately two-minute intervals.                                                                         looked. In Alaska, only one breath test
                                                                                                                       is used. The practice is to not require
                                                                                                                       an additional 15-minute waiting peri-
      within 15 minutes in some states and                              out of 25 subjects without dentures            od after obtaining an “invalid sample.”
      20 minutes in other states. Thus states                           and 5 out of 25 subjects with dentures         Thus, as seen in Figures 3 and 4, it is
      will require either a 15-minute or 20-                            and adhesives. They also found that            likely that the following valid breath
      minute waiting period to precede a                                mouth alcohol lasted more than 20              test will be greater than the correct
      breath alcohol test. A concern has been                           minutes in no subjects without den-            BrAC if it is administered before an
      those subjects with dentures, particu-                            tures and 2 out or 25 subjects with            additional 15 minutes waiting period
      larly using adhesives. Harding17 studied                          dentures using adhesives. A case study         is completed.
      25 subjects who used dentures with                                by Trafford18 indicated that there was a             In our experiments, we also noted a
      and without their dentures for the                                possibility of dentures contributing to        propensity for an erroneous high BrAC
      retention time of mouth alcohol.                                  a falsely high breath test.                    test during the absorption phase. This
      These authors found that mouth alco-                                   In addition, a study by Logan et al19     may be due to the potential for mouth

      hol lasted more than 15 minutes in 5                              showed that medications in asthma              alcohol to be missed by the slope detec-

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60    W W W. N A C D L . O R G                                                                                                     THE CHAMPION
tor immediately after consumption of                  4. McFadden ER, Jr. Heat and water              14. Wigmore J, Leslie G. The effect of
alcohol. Jones20 has observed that BrAC         exchange in human airways. Am. Rev.             swallowing or rinsing alcohol solution on
is sometimes greater than the venous            Respir. Dis. 1992;146(5 Pt 2):S8-S10.           the mouth alcohol effect and slope detec-
blood sample BAC within the first 90                  5. George SC, Babb AL, Hlastala MP.       tion of the Intoxilyzer 5000. J Anal Toxicol.
minutes (the absorptive phase) follow-          Modeling the concentration of ethanol in        2001;25:112-114.
ing ingestion.                                  the exhaled breath following pretest                  15. Kechagias S, Jonsson K, Franzen T,
                                                breathing maneuvers. Annals of Bio Eng.         Andersson L, Jones A. Reliability of breath-
Not Useful                                      1995;23:48-60.                                  alcohol analysis in individuals with gastroe-
     In summary, this study has shown                 6. Id.                                    sophageal reflux. J FORENS SCI. 1999;44:814-
that mouth alcohol may play a role in                 7. Hlastala M, Swenson E. Airway gas      818.
many breath tests even though a BTU             exchange. In: The Bronchial Circulation. Ed.:         16. Staubus A. False high breath alco-
uses a slope detector. While slope detec-       J.Butler. Exec Ed: C Lenfant. Marcel Dekker,    hol readings due to gastric reflux. Proc
tors are present in all modern infrared         Inc.; 1992:pp. 417-441.                         Amer Acad Forens Sci. 1999:287-288.
absorption BTUs, they are not useful in               8. Anderson J, Babb A, Hlastala M. Mod-         17. Harding P, McMurray M, Laessig R,
many cases. This problem with the slope         eling soluble gas exchange in the airways       Simley DI, Correll P,Tsunehiro J.The effect of
detector argues quite strongly that dupli-      and alveoli. ANN BIOMED ENG. 2003;31:1-21.      dentures and denture adhesive on mouth
cate breath tests with 15 min between                 9. Jones AW. How breathing technique      alcohol retention. J FORENS SCI. 1992;37:999-
tests should be used in all cases in order      can influence the results of breath-alcohol     1007.
to minimize the chance of mouth alcohol         analysis. MED. SCI. LAW. 1982;22(4):275-280.          18. D, Makin H. Breath-alcohol concen-
influencing the breath test result.                   10. George SC, Babb AL, Hlastala MP.      tration may not always reflect the concen-
                                                Dynamics of soluble gas exchange in the         tration of alcohol in blood. J ANAL TOXICOL.
Notes                                           airways: III. Single exhalation breathing       1994;18:225-228.
     1. Hlastala M. The alcohol breath test -   maneuver. J. APPL. PHYSIOL. 1993;75(6):2439-          19. Logan B, Distefano S, Case G. Eval-
A brief review. J Appl Physiol. 1998;84:401-    2449.                                           uation of the effect of asthma inhalers and
408.                                                  11. Jones AW. Effects of temperature      nasal decongestant sprays on a breath
     2. McFadden ER. Respiratory heat and       and humidity of inhaled air on the concen-      alcohol test. J FORENSIC SCI. 1998;43:197-
water exchange: physiologic and clinical        tration of ethanol in a man’s exhaled           199.
implications. J. Appl. Physiol. 1983;54:331-    breath. Clin. Sci. 1982;63:441-445.                   20. Jones A. Disposition and fate of
336.                                                  12. BAC DataMaster Supervisor Guide       ethanol in the body. In: GARRIOTT J, ED. MED-
     3. Tsu ME, Babb AL, Ralph DD, Hlastala     patBDDcBOG, page 6 (National Patent Ana-        ICAL-LEGAL ASPECTS OF ALCOHOL. 4TH ED. Tucson,
MP. Dynamics of heat, water, and soluble        lytical Systems, Inc., Mansfield, Ohio).        AZ: Lawyers & Judges Publishing Company,
gas exchange in the human airways: I. A               13. Evans J.The effect of mouth alcohol   Inc.; 2003:83. s

model study. Ann. Biomed. Eng.                  on the Intoxilyzer 5000. J Alc Testing All.
1988;16:547-571.                                2002;4:12-16.

 About the Authors
 Michael P. Hlastala is a Professor of Phys-     Wayne J. E. Lamm is a Research Scientist        James Nesci is the managing partner of
                       iology & Biophysics                             IV at the University                            Nesci, St. Louis &
                       at the University of                            of     Washington,                              West, PLLC in Tuc-
                       Washington, Seattle                             Seattle WA in the                               son, Arizona and is
                       WA in the Depart-                               Department of Pul-                              Board Certified by
                       ment of Pulmonary                               monary & Critical                               the National College
                       & Critical Care Med-                            Care Medicine. Mr.                              for DUI Defense. He
                       icine. He has per-                              Lamm has B. A. and                              is the author of the
                       formed research in                              M. A. degrees from                              upcoming book, Ari-
                       the fields of pul-                              the University of                               zona DUI Defense:
                       monary       disease                            Missouri, Columbia,                             The Law & The Prac-
 and human physiology for 38 years. He           MO. He has worked in the field of lung          tice. He has appeared on Inside Edition,
 has consulted in both criminal and civil        physiology since 1978 doing human               Celebrity Justice, Fox News and Court TV.
 legal cases related to alcohol for 20           and animal research. He has been an             He was one of the lead attorneys on the
 years.                                          author on nearly fifty publications in this     Intoximeters® RBT-IV breath-testing issue
                                                 field.                                          in Southern Arizona which resulted in the
 Michael P. Hlastala, Ph.D.                                                                      suppression of breath tests in over 3,000
 Department of Physiology & Biophysics           Wayne J. E. Lamm                                cases and he represented singer, Diana
 Dept. of Medicine                               Dept. of Medicine                               Ross on DUI charges in Tucson.
 University of Washington                        University of Washington
 Seattle, WA 98195-6522                          Seattle, WA 98195-6522                          James Nesci
 206-543-3166                                    206-543-0544                                    216 North Main Avenue
 Fax 206-685-8673                                Fax 206-685-8673                                Tucson Arizona 85701
   E-MAIL                E-MAIL                  520-622-1222
                                                                                                 Fax 520-624-7817

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