Minimum lung function for breath alcohol testing using the Lion Alcolmeter SD-400.

The aim of this study was to determine the minimum lung function required by an individual to complete a breath alcohol test successfully using a Lion Alcolmeter SD-400. A total of 331 subjects routinely referred to a busy clinical respiratory function laboratory for assessment of their lung function were tested. A total of 52 (15.7%) of these subjects were unable to provide an adequate sample after two attempts. The majority of the group (86.5%) were female. There was considerable overlap of the minimum lung function parameters between those subjects who were unsuccessful at all attempts and those who were successful. The failure rate of the subjects using the Lion Alcolmeter SD-400 was approximately 50% of that found in a previous study of the Lion SD-2.     

Exhaled breath for drugs of abuse testing — Evaluation in criminal justice settings

Exhaled breath is being developed as a possible specimen for drug testing based on the collection of aerosol particles originating from the lung fluid. The present study was aimed to evaluate the applicability of exhaled breath for drugs of abuse testing in criminal justice settings. Particles in exhaled breath were collected with a new device in parallel with routine urine testing in two Swedish prisons, comprising both genders. Urine screening was performed according to established routines either by dipstick or by immunochemical methods at the Forensic Chemistry Laboratory and confirmations were with mass spectrometry methods. A total of 247 parallel samples were studied. Analysis of exhaled breath samples was done with a sensitive mass spectrometric method and identifications were made according to forensic standards. In addition tested subjects and personnel were asked to fill in a questionnaire concerning their views about drug testing. In 212 cases both the urine and breath testing were negative, and in 22 cases both urine and breath were positive. Out of 6 cases where breath was negative and urine positive 4 concerned THC. Out of 7 cases where, breath was positive and urine negative 6 concerned amphetamine. Detected substances in breath comprised: amphetamine, methamphetamine, THC, methylphenidate, buprenorphine, 6-acetylmorphine, cocaine, benzoylecgonine, diazepam and tramadol. Both the prison inmates and staff members reported breath testing to be preferable due to practical considerations. The results of this study documented that drug testing using exhaled breath provided as many positives as urine testing despite an expected shorter detection window, and that the breath sampling procedure was well accepted and provided practical benefits reported both by the prison inmates and testing personnel.     

Fatal acute selenium toxicity

Selenium is used widely in industry and as a dietary supplement. Reports of acute selenium toxicity are infrequent, however, and the relationship of toxicity to selenium concentrations in blood and tissues has not been established. We describe a patient who died eight days after ingesting selenious acid in the form of gun blueing. The patient's clinical course demonstrated many of the features of inorganic selenium toxicity described in animals; hypotension as a result of both vasodilation and decreased cardiac output, adult respiratory distress syndrome, severe myopathy which contributed to respiratory failure, and a garlicky odor to the breath. Four days after ingestion the serum selenium concentration was twenty times normal and urinary excretion seventy times normal. Postmortem tissue selenium concentrations were up to 40 times normal.     

Breath alcohol test precision: an in vivo vs. in vitro evaluation

Random error is associated with breath alcohol measurements, as with all analytical methods. The total random uncertainty of a group of n measurements is typically determined by computing the standard deviation and requiring it to be less than some appropriate level (i.e., +/- 0.0042 g/210 l). The total random uncertainty has two primary sources; the instrumental method and the sample source. These are typically inseparable values. In breath alcohol testing the two primary sample sources are simulators and human breath. The present study evaluates ten groups of simulator samples consisting of ten measurements each on BAC Verifier Datamaster instruments. The data also includes ten breath alcohol measurements from each of 21 individuals following alcohol consumption. The range of standard deviations for the simulator samples was 0.0003-0.0022 g/210 l. The range of standard deviations for the human breath samples was 0.0015-0.0089 g/210 l. Two statistics that test for homogeneity for variances were applied. The simulator samples resulted in a Cochran's C test of 0.5000 and an Fmax test of 48.9. The human breath samples resulted in a Cochran's C test of 0.1519 and an Fmax test of 27.3. All were significant at P less than 0.001. The statistical tests demonstrated that the intragroup variability among the human subjects was comparable to the intragroup variability among the simulator samples. The data also demonstrates that the sample source (simulator or human) is probably the largest contributor to total random uncertainty. Therefore, when duplicate breath alcohol testing from individuals shows variability in the second decimal place the cause is differences in breath samples provided and not instrumental imprecision.     

The Effects of Gastroesophageal Reflux Disease on Forensic Breath Alcohol Testing

Fifteen test subjects, 10 of whom were diagnosed with gastroesophageal reflux disease (GERD), were dosed with alcohol to BACs above 0.150 g/dL. Blood and breath assays taken at 20-min intervals for 8 h after dosing demonstrated close agreement between postabsorptive BAC and BrAC values. Three subjects exhibited elevated breath alcohol concentrations up to 0.105 g/dL during the absorptive phase that were apparently due to the passage of gastric alcohol through the lower esophageal sphincter not attributable to eruction or regurgitation. The effect of gastric alcohol was not consistently proportional to the amount of unabsorbed gastric alcohol. Absorption of alcohol in the esophagus explains the nonproportionality. Breath samples contaminated by GERD-related alcohol leakage from the stomach into a breath sample were found only when there was a high concentration of alcohol in the stomach. When contaminated breath samples were encountered, they were irreproducible in magnitude.     

Death from Nitrous Oxide

Nitrous oxide is an inflammable gas that gives no smell or taste. It has a history of abuse as long as its clinical use, and deaths, although rare, have been reported. We describe two cases of accidental deaths related to voluntary inhalation of nitrous oxide, both found dead with a gas mask covering the face. In an attempt to find an explanation to why the victims did not react properly to oncoming hypoxia, we performed experiments where a test person was allowed to breath in a closed system, with or without nitrous oxide added. Vital signs and gas concentrations as well as subjective symptoms were recorded. The experiments indicated that the explanation to the fact that neither of the descendents had reacted to oncoming hypoxia and hypercapnia was due to the inhalation of nitrous oxide. This study raises the question whether nitrous oxide really should be easily, commercially available.     

An autopsy case of intraoperative death due to pulmonary fat embolism--possibly caused by release of tourniquet after multiple muscle-release and tenotomy of the bilateral lower limbs

Acute interstitial pneumonitis (AIP), also known as Hamman-Rich syndrome, is a distinct type of idiopathic interstitial pneumonia affecting patients of both genders without pre-existing lung diseases. We describe the case of a fulminant form of AIP and discuss the pathophysiological mechanisms of AIP with reference to the histological pattern. A 15-year-previously-healthy male boy presented to the Hospital with a 6-day history of malaise, fever and cough. The clinical prodromes were followed by the acute onset of increasing shortness of breath rapidly progressing in acute respiratory failure. Chest X-ray demonstrated bilateral diffuse airspace opacification; the high resolution CT confirmed the presence of bilateral, symmetric diffuse ground-glass attenuation. The patient was admitted to the intensive care unit, but died after few hours. An autopsy was performed within 24h. The histological examination of lung specimens showed a pattern of diffuse alveolar damage. immunohistochemical, microbiological and toxicological tests were also carried out. The clinical presentation, the histological findings and the exclusion of infective, traumatic, toxic and metabolic causes of acute respiratory distress syndrome (ARDS) allowed us to conclude that the boy was affected by AIP. In conclusion, AIP is a diagnosis of exclusion. It has a mortality rate ranging about 50%, despite mechanical ventilation. In fatal cases of AIP diagnosis can be based on clinical presentation, radiological, histological and microbiological findings and can be further confirmed by immunohistochemical analysis.     

Breath alcohol analysis in one subject with gastroesophageal reflux disease.

A large number of people suffer from the heartburn symptoms associated with gastroesophageal reflux disease (GERD). Relatively little has been published on its potential for biasing a breath alcohol measurement. The present case describes an individual (white male, aged 23) who experimentally consumed 1.0 g/kg of an alcohol beverage and subsequently provided breath and blood samples for analysis. Breath expirograms were also collected following several different preexhalation breathing maneuvers. Shortly after the end of drinking the mean of replicate breath alcohol results exceeded that of the corresponding venous blood alcohol. A later paired comparison (during the postabsorptive phase) showed the blood alcohol to exceed the breath. None of the expirograms provided evidence that "mouth alcohol" due to gastroesophageal reflux had biased any test results. People with GERD can provide biased-free end-expiratory breath alcohol results where sound forensic practice is followed, which includes: 15-min. preexhalation observation, duplicate testing, instrumental detection systems, and trained alert operators who ask appropriate questions and watch for associated signs.     

Reliability of breath-alcohol analysis in individuals with gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is widespread in the population among all age groups and in both sexes. The reliability of breath alcohol analysis in subjects suffering from GERD is unknown. We investigated the relationship between breath-alcohol concentration (BrAC) and blood-alcohol concentration (BAC) in 5 male and 5 female subjects all suffering from severe gastroesophageal reflux disease and scheduled for antireflux surgery. Each subject served in two experiments in random order about 1-2 weeks apart. Both times they drank the same dose of ethanol (approximately 0.3 g/kg) as either beer, white wine, or vodka mixed with orange juice before venous blood and end-expired breath samples were obtained at 5-10 min intervals for 4 h. An attempt was made to provoke gastroesophageal reflux in one of the drinking experiments by applying an abdominal compression belt. Blood-ethanol concentration was determined by headspace gas chromatography and breath-ethanol was measured with an electrochemical instrument (Alcolmeter SD-400) or a quantitative infrared analyzer (Data-Master). During the absorption of alcohol, which occurred during the first 90 min after the start of drinking, BrAC (mg/210 L) tended to be the same or higher than venous BAC (mg/dL). In the post-peak phase, the BAC always exceeded BrAC. Four of the 10 subjects definitely experienced gastric reflux during the study although this did not result in widely deviant BrAC readings compared with BAC when sampling occurred at 5-min intervals. We conclude that 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.     

The elimination rate of mouth alcohol: mathematical modeling and implications in breath alcohol analysis.

Mouth alcohol, if present in high enough concentrations, can falsely bias the accurate measurement of end-expiratory breath alcohol. Mouth alcohol will be eliminated over time, however, and can be modeled with a single term decaying exponential of the form: B0e-kt + C. It is important, however, to determine the model and its parameters when alcohol is already present within the biologic system. Using three individuals as their own controls, mouth alcohol was administered both before and after alcohol consumption followed by breath alcohol analysis performed at approximately 0.5 min intervals. The results showed that both model parameters (B0 and k) are effected and that the asymptotic value (C) is reached much sooner when alcohol already exists in the end-expiratory breath. Considering only three individuals were involved, the forensic-science importance appears to be that, as the end-expiratory breath alcohol concentration increases, the time necessary for the mouth alcohol to decrease to unbiased levels is decreased. Fifteen min of observation time prior to breath alcohol analysis appears to be more than adequate at forensically relevant concentrations.     

The laboratory testing of evidential breath-testing (EBT) machines

Six types of evidential breath testing (EBT) machines were tested in a laboratory. The testing experiments are classified into three paragraphs: analytical performance, sampling and operating conditions. In order to characterize the analytical performance a set of parameters (repeatability, reproducibility, linearity, accuracy, specificity) was established. The results were, in general, good, although an underestimation of the actual vapour concentration was observed. Different types of EBT machines showed significant differences measuring the same vapour.     

Model experiments on breathing under sand

Remarkable autopsy findings in persons who had suffocated as a result of closure of the mouth and nose by sand (without the body being buried) induced us to investigate some aspects of this situation by means of a simple experiment. A barrel (diameter 36.7 cm) with a mouthpiece in the bottom was filled with sand to a depth of 15, 30, 60, or 90 cm. The subject tried to breathe as long as possible through the sand, while the amount of sand inspired was measured. Pressure and volume of the breath, as well as the O2 and CO2 content were also measured. A respiratory volume of up to 31 was possible, even when the depth was 90 cm. After about 1 min in all trials, the subject's shortness of breath forced us to stop the experiment. Measurement of O2 and CO2 concentrations proved that respiratory volume in and out of the sand shifts to atmospheric air without gas exchange, even when the sand depth is 15 cm. Sand aspiration depended on the moisture of the material: when the sand was dry, it was impossible to avoid aspiration. However, even a water content of only 5% prevented aspiration, although the sand seemed to be nearly dry.     

A large-scale study of the relationship between blood and breath alcohol concentrations in New Zealand drinking drivers

Blood alcohol concentrations (BAC) and corresponding breath alcohol concentrations (BrAC) were determined for 21,582 drivers apprehended by New Zealand police. BAC was measured using headspace gas chromatography, and BrAC was determined with Intoxilyzer 5000 or Seres Ethylometre infrared analysers. The delay (DEL) between breath testing and blood sampling ranged from 0.03 to 5.4 h. BAC/BrAC ratios were calculated before and after BAC values were corrected for DEL using 19 mg/dL/h as an estimate of the blood alcohol clearance rate. Calculations were performed for single and duplicate breath samples obtained using the Intoxilyzer (groups I-1 and I-2) and Seres devices (groups S-1 and S-2). Before correction for DEL, BAC/BrAC ratios for groups I-1, I-2, S-1, and S-2 were (mean+/-SD) 2320+/-260, 2180+/-242, 2330+/-276, and 2250+/-259, respectively. After BAC values were adjusted for DEL, BAC/BrAC ratios for these groups were (mean+/-SD) 2510+/-256, 2370+/-240, 2520+/-280, and 2440+/-260, respectively. Our results indicate that in New Zealand the mean BAC/BrAC ratio is 19-26% higher than the ratio of the respective legal limits (2000).     

Minimum respiratory function for breath alcohol testing in South Australia.

The aim of this study was to determine if inability to complete a breath alcohol test successfully, using a Lion Alcolmeter SD-2 or Drager Alcotest 7110, was related to any of the standard parameters obtained from the lung function spirometry test. A total of 153 subjects referred to a clinical laboratory for routine lung function testing were tested using the Alcolmeter, 158 using the Alcotest, with 69 subjects completing tests on both instruments. Of the 153 patients who volunteered to use the Alcolmeter, 49 (32%) were unable to produce a valid test effort on this instrument. One subject failed to complete a satisfactory test using the Alcotest, and one was unable to master the technique. There was considerable overlap of the minimum value for each of the lung function parameters of those subjects who could or could not successfully complete the breath alcohol test. It is recommended that changes are made to both of the instruments, the techniques used and the legislation, to minimize the number of breath alcohol testing failures and to reduce the variability of the results.     

The Measurand Problem in Breath Alcohol Testing

Proper interpretation of forensic measurements can be critical to the administration of justice. Breath alcohol testing is commonly relied upon to measure the concentration of alcohol in breath or, indirectly, in blood. The concentration sought constitutes the “quantity intended to be measured,” referred to as the measurand. Although breath tests always probe the same physical quantity, their measurand is dictated by statute and varies between jurisdictions. Thus, identical numerical values obtained from tests in disparate jurisdictions may refer to different quantities and may not indicate the relevant statutory measurand. This can lead to misinterpretation of results, referred to as the “measurand problem.” We first illustrate the concept of the measurand. Thereafter, the measurand problem is illustrated through application of Hlastala's breath test paradigm and Gullberg's work on breath test uncertainty. It is shown that where the measurand is not properly accounted for, conclusions based upon breath test evidence are undermined.     

Evaluation of breath-alcohol instruments. IV. Roadside tests with Alcolmeter pocket model

This paper reports results from a field trial with a breath-alcohol screening device--Alcolmeter pocket model. Breath tests were made with drivers apprehended during routine controls (road-blocks), for traffic violations and those involved in traffic accidents. Of 908 roadside breath tests made with chemical reagent tubes, 343 showed zero alcohol (no colour change) and these results were confirmed by Alcolmeter. Alcohol was detected in 191 tests but the level was judged as being below the legal limit of 0.50 mg/ml. The Alcolmeter results, however, ranged from 0 to 1.22 mg/ml (mean 0.21 mg/ml) and 15 individuals (7.8%) were above the legal limit. There were 373 positive chemical tube breath screening tests whereas in 5 cases (1.3%) Alcolmeter indicated a blood-alcohol level below 0.50 mg/ml. Duplicate determinations with the Alcolmeter device were highly correlated r = 0.93 +/- 0.02 (+/- S.E.), P less than 0.001. The standard deviation of a single breath-alcohol analysis under field conditions was +/- 0.10 mg/ml which corresponds to a coefficient of variation of 10%. The time interval between positive roadside breath test and blood-sampling ranged from 5 to 220 min (median 62 min). The results were therefore adjusted by 0.15 mg/ml per hour to compensate for ethanol metabolised between the time of sampling blood and breath. The corrected blood and breath values were well correlated r = 0.84 +/- 0.03, P less than 0.001 but the predictive power of the regression relationship was poor. The regression equation was y = 0.27 +/- 0.65x and the standard error estimate was +/- 0.21 mg/ml at the mean concentration of ethanol of 1.0 mg/ml.     

Testing Antemortem Blood for Ethanol Concentration from a Blood Kit in a Refrigerator Fire

The stability of ethanol in antemortem blood stored under various conditions has been widely studied. Antemortem blood samples stored at refrigerated temperature, at room temperature, and at elevated temperatures tend to decrease in ethanol concentration with storage. It appears that the stability of ethanol in blood exposed to temperatures greater than 38°C has not been evaluated. The case presented here involves comparison of breath test results with subsequent analysis of blood drawn at the time of breath testing. However, the blood tubes were in a refrigerator fire followed by refrigerated storage for 5 months prior to analysis by headspace gas chromatography. The subject’s breath was tested twice using an Intoxilyzer 8000. The subject’s blood was tested in duplicate using an Agilent headspace gas chromatograph. The measured breath ethanol concentration was 0.103 g/210 L and 0.092 g/210 L. The measured blood ethanol concentration was 0.0932 g/dL for both samples analyzed. Although the mean blood test result was slightly lower than the mean breath test result, the mean breath test result was within the estimated uncertainty of the mean blood test result. Even under the extreme conditions of the blood kit being in a refrigerator fire, the measured blood ethanol content agreed well with the paired breath ethanol test.     

The rate of dissipation of mouth alcohol in alcohol positive subjects

Seven subjects participated in a two-part study to evaluate mouth alcohol dissipation in alcohol positive subjects. In part one, subjects rinsed their mouths with a vodka solution and were breath tested after 1, 2, 3, 4, and 5 min intervals. On average, breath alcohol concentration (BrAC) decreased 20.4% (range 3.2-47.9%) between 1 and 2 min after rinsing. In part two of the study, multiple breath tests were administered after rinsing once with the vodka solution. The BrAC decreased more than 0.020 g/210 L between the first and second tests for all subjects (average 0.095 g/210 L, range 0.021-0.162 g/210 L). The average time for subjects to reach their unbiased BrAC was 9.35 min (range 4-13 min) after rinsing. This study reaffirms the need for duplicate breath testing and confirms that the minimum of a 15-min observation period is sufficient for mouth alcohol to dissipate in alcohol positive subjects.     

Paradigm Shift for the Alcohol Breath Test

Abstract: The alcohol breath test (ABT) has been used for quantification of ethyl alcohol in individuals suspected of driving under the influence for more than 50 years. In this time, there has been little change in the concepts underlying this single breath test. The old model, which assumes that end‐exhaled breath alcohol concentration is closely related to alveolar air alcohol concentration, is no longer acceptable. This paper reviews experimental research and mathematical modeling which has evaluated the pulmonary exchange processes for ethyl alcohol. Studies have shown that alcohol exchanges dynamically with the airway tissue both during inspiration and expiration. The airway tissue interaction makes it impossible to deliver air with alveolar alcohol concentration to the mouth. It is concluded that the ABT is dependent on physiological factors that need to be assessed for accurate testing.     

New Zealand's breath and blood alcohol testing programs: further data analysis and forensic implications

Paired blood and breath alcohol concentrations (BAC, in g/dL, and BrAC, in g/210 L), were determined for 11,837 drivers apprehended by the New Zealand Police. For each driver, duplicate BAC measurements were made using headspace gas chromatography and duplicate BrAC measurements were made with either Intoxilyzer 5000, Seres 679T or Seres 679ENZ Ethylometre infrared analysers. The variability of differences between duplicate results is described in detail, as well as the variability of differences between the paired BrAC and BAC results. The mean delay between breath and blood sampling was 0.73 h, ranging from 0.17 to 3.1 8h. BAC values at the time of breath testing were estimated by adjusting BAC results using an assumed blood alcohol clearance rate. The paired BrAC and time-adjusted BAC results were analysed with the aim of estimating the proportion of false-positive BrAC results, using the time-adjusted BAC results as references. When BAC results were not time-adjusted, the false-positive rate (BrAC>BAC) was 31.3% but after time-adjustment using 0.019 g/dL/h as the blood alcohol clearance rate, the false-positive rate was only 2.8%. However, harmful false-positives (defined as cases where BrAC>0.1 g/210L, while BAC< or =0.1g/dL) occurred at a rate of only 0.14%. When the lower of duplicate breath test results were used as the evidential results instead of the means, the harmful false-positive rate dropped to 0.04%.