Asian Cardiovascular
and Thoracic Annals
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Can Chest Trauma Patients Provide Breath Sample with Lion SD-400 Alcometer?
Sridhar Rathinam, David Luke, Prakash Nanjaiah, Maninder S Kalkat and Richard S Steyn
Asian Cardiovascular and Thoracic Annals 2009 17: 282
DOI: 10.1177/0218492309104774
The online version of this article can be found at:
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ORIGINAL ARTICLE
Can Chest Trauma Patients Provide Breath
Sample With Lion SD-400 Alcometer?
Sridhar Rathinam, FRCSEd(CTh), David Luke, MRCS, Prakash Nanjaiah, MRCS,
Maninder S Kalkat, FRCSEd(CTh), Richard S Steyn, FRCSEd(CTh)
Regional Department of Thoracic Surgery
Birmingham Heartlands Hospital
Bordesley Green East, Birmingham, UK
ABSTRACT
Various investigators have addressed the minimum lung function required to activate
breathalyzers, and the impact of comorbid respiratory illness. We postulated that
subjects with significant chest trauma may have difficulty in providing an adequate
breathalyzer sample. A prospective self-controlled study of 20 patients who underwent
thoracotomy was conducted between August 2005 and December 2005, using a Lion
Alcometer SD-400. The mean age of the patients was 69.3 years (range, 37–83 years).
Preoperatively, their mean forced expiratory volume was 1.97 L (range, 1.19–2.46 L),
and peak expiratory flow rate was 240 L min1 (range, 126–520 L min1).
Postoperatively, mean forced expiratory volume was 1.14 L (range, 0.34–2.2 L) and
peak expiratory flow rate was 179 L min1 (range, 36–492 L min1). These decreases
were highly significant. All patients activated the breathalyzer device preoperatively,
but only 2 (10%) could activate it postoperatively. Extrapolating this to patients with
chest injury, most may find it impossible to activate breathalyzers.
(Asian Cardiovasc Thorac Ann 2009;17:282–4)
KEYWORDS: Alcohol Drinking, Breath Tests, Thoracic Injuries, Thoracic Surgery.
INTRODUCTION
British police have been using roadside alcohol testing
since 1967, and it is now mandatory in drivers stopped
with a suspicion of drinking.1 As with many other police
forces, they also screen drivers involved in collisions.
Drivers are initially tested with a breathalyzer at the
roadside.2 If positive, evidential breath testing is
performed again at a police station. Various investigators have addressed the impact of comorbid respiratory
illnesses and the minimum lung function required to
activate various breathalyzers.3–5 It is accepted that
chronic obstructive pulmonary disease may cause
difficulty in undertaking such tests, and that forced
expiratory volume in the 1st second (FEV1) and forced
vital capacity (FVC) are the most reliable indicators.
Significant chest trauma may also cause difficulty in
providing a breath sample. This depends on the
significance and severity of the injury. This study was
conducted to determine whether a breathalyzer can be
activated by a person with significant chest trauma.
Patients who had undergone thoracic surgery were used
as models of chest trauma due to vehicle collision.
PATIENTS AND METHODS
A prospective self-controlled study was performed in
20 patients who underwent thoracic surgical procedures
in Birmingham Heartlands Hospital between August
and December 2005. Ethics committee approval was
obtained, and the patients were counseled and consented
into the study. Thoracotomy with lung resection was
used as a model of rib fractures with pulmonary
contusion, and sternotomy was used as a model of
sternal fracture. We excluded patients who could
not activate the breathalyzer preoperatively and those
with a tracheostomy or tracheal problems who could
not use the device. The mean age was 69.3 years
Richard S Steyn, FRCSEd(CTh)
Tel: þ44 121 424 2562
Fax: þ44 121 424 0562
Email: [email protected]
Regional Department of Thoracic Surgery, Birmingham Hertlands Hospital, Bordesley Green East, Birmingham B9 5SS,
United Kingdom.
doi: 10.1177/0218492309104774
ß SAGE Publications 2009 Los Angeles, London, New Delhi and Singapore
ASIAN CARDIOVASCULAR & THORACIC ANNALS
2009, VOL. 17, NO. 3
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Rathinam
Chest Trauma and Breathalyzers
Table 1. Surgical procedures in 20 patients
Procedure
Mean Age (years)
Male
Total
Lobectomy
Decortication
Pneumonectomy
Wedge excision
Exploratory thoracotomy
Median sternotomy
Repair of diaphragm
71.8
60
59
70
75
79
60
5
5
0
3
2
1
1
7
5
1
3
2
1
1
Figure 2. Changes in forced expiratory volume in 1st sec
(FEV1) before and after surgery.
3.5
adequate analgesia and the evaluation was performed
after they had recovered from physiotherapy exercises.
We felt this was equivalent to a chest trauma patient
receiving morphine for analgesia. The spirometry was
repeated on this occasion, and recorded.
FEV1 in litters
3
2.5
2
1.5
1
Changes in FEV1 and PEFR were analyzed using paired
Student t tests. A value of p < 0.05 was considered
significant.
0.5
0
Pre Op FEV1
Post Op FEV1
Figure 1. The Lion Alcometer SD-400.
RESULTS
Preoperatively, the mean FEV1 was 1.97 L (range,
1.19–2.46 L), and mean PEFR was 240 L min1 (range,
126–520 L min1). Thoracic epidural pain relief was used
in 12 patients, and 8 had intrathecal morphine followed
by morphine infusion. After surgery, there was a decrease
in both FEV1 and PEFR, irrespective of the surgical
procedure (Figure 2). Postoperatively, the mean FEV1
was 1.14 L (range, 0.34–2.2 L) and PEFR was
179 L min1 (range, 36–492 L min1). The decreases in
FEV1 and PEFR in the postoperative period were both
highly significant ( p ¼ 0.000). All patients were able to
activate the device preoperatively, but only 2 (10%) could
activate it postoperatively; these 2 patients were males
who had undergone decortication.
(range, 37–83 years), and 17 (85%) patients were male.
All underwent spirometry to assess lung function, as
part of their preoperative assessment. Operative procedures are listed in Table 1. A median sternotomy was
performed in 1 patient, and the others underwent a
posterolateral thoracotomy. All patients had general
anesthesia and double-lumen endotracheal intubation
with single-lung anesthesia. They were extubated on
the operating table, and transferred to the thoracic highdependency unit.
The Lion Alcometer SD-400 is a microprocessorcontrolled multi-filtering infrared spectrometer that
incorporates a flow meter to measure FEV1 and peak
expiratory flow rate (PRFR), which trigger the device.
The spectrometer analyses the breath sample for
alcohol (Figure 1). We investigated patients’ ability to
activate the device without alcohol (dry activation).
Preoperatively, patients were briefed about the device
and its function, and it was used according to the
manufacturer’s instructions.6 The Alcometer was calibrated, and a disposable mouth piece was attached. The
patient was asked to take a deep breath in, and exhale
into the device through the mouth. When the device is
activated, there is a change of indicator color from red to
green. The best of 3 attempts was taken into consideration. Inability to activate the device after 3 attempts was
accepted as failure. This procedure was repeated on the
2nd postoperative day. We ensured that patients had
2009, VOL. 17, NO. 3
DISCUSSION
Various studies have investigated the impact of lung
function on ability to activate a breathalyzer. FEV1 is
a significant indicator of ability to activate a breathalyzer, but the threshold value may vary with the type of
device. Briggs and colleagues3 suggested that subjects
with FEV1 < 1.5 L or FEV1 < 50% of predicted were
unlikely to activate the Alcometer. Another study
suggested higher minimum values, showing that subjects with FEV1 < 2 L and FVC < 2.6 L were unable to
use any device.4 More recently, Honeybourne and
colleagues5 reported continuing difficulties in the ability
of some subjects to use the Lion Intoxilyser 6000 breath
alcohol device, which is the model used by police in the
283
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Rathinam
Chest Trauma and Breathalyzers
UK, in a study attempting to validate this device in
patients with chronic lung disease. The device usually
requires a minimum sample volume of 1.2 L, with flow
rate maintained 412 L min1. A Canadian study on the
device used by Ontario police indicated that all patients
with FVC41.43 L could perform the test, whereas 75%
of those with FVC < 1 L caused by airway obstruction
were unable to provide an adequate sample.7 These
findings highlight the need for adequate lung function
to maintain a steady airflow through the device to
activate it.
injuries in road accidents may be associated with brain
concussion and other injuries, shock, and fear. A
limitation of this study is that the mean age of the
patients is probably higher than that of motorists driving
under the influence of alcohol. Further studies may be
needed in a younger cohort.
Extrapolating these findings in patients who had chest
surgery, we can assume that presently available devices
are difficult to activate by drivers who suffer chest
trauma. This group require alternative methods to
estimate alcohol levels.
Anyone who fails to provide an adequate breath sample
for alcohol testing may be charged with refusing to
supply a sample, unless he convinces the police officer
that he is genuinely unable to do so.4 Rib fractures, pain,
pulmonary contusions, and impaired diaphragmatic
movement all contribute to diminished lung function
after chest injuries. Ventilatory capacity (FEV1) and
vital capacity are reduced, and the residual volume is
increased after chest injury.8 In a study using mathematical models, it was shown that failure to achieve full
inspiration reduces the breath alcohol content at full
exhalation, and reduced inhaled volume and can lead to
inability to provide an adequate breath volume.9 It also
demonstrated that alcohol exchange within the airways
during the single-exhalation breath test is dependent on
lung size. This may lead to bias against people with
smaller lung size.9
ACKNOWLEDGMENT
The Lion Alcometer SD-400 was provided by Lion
Laboratories.
REFERENCES
We postulated that patients with significant chest
injuries would not be able activate the breath analysis
device due to pain and compromised respiratory function. In testing this hypothesis on patients undergoing
thoracic surgical procedures, we chose the 2nd postoperative day because they were on patient-controlled
morphine analgesia rather than epidural or intrathecal
morphine, which are not comparable to the morphine
analgesia provided by pre-hospital care practitioners or
accident and emergency departments. Their decrease in
lung function highlights the importance of pain and loss
of chest wall mechanics in a postoperative or post-chest
injury patient, in spite of adequate analgesia. Thoracic
operations are a form of controlled trauma, but chest
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