Detailed Procedure for Measuring Volatile Sulfur Compounds with the Halimeter® Jon L. Richter, DMD, PhD

Includes methods for mouth, nose, and lung air sampling Please ignore all references to the recorder or penwriter, if you are not using one. The breath sampling procedure is the same regardless of recording equipment. Steps 4, 19, and 23 are simplified in the newer model Halimeter, with built in countdown timer. Step 20 is automated in the newer model, as sample data stops being collected after 30 seconds.

Dr. Jon L. Richter is the Founding Director of the Richter Center for the Treatment of Breath Disorders in Philadelphia, PA. Dr. Richter’s program has achieved international recognition as the first facility of its kind in the world devoted exclusively to the diagnosis, treatment, and research of breath disorders.

Preparation for Sampling

1.  Verify that the patient has followed appropriate pre-visit instructions (no food, smoking, drinking, oral hygiene, etc. for 4-10 hrs.)

2.  The concentrations of volatile sulfur compounds in mouth air (VSCm), lung air (VSCl), and nasal air (VSCn) are recorded with the Halimeter and, optionally, with a penwriter (available through Interscan Corporation). The Halimeter should be kept plugged in when not in use, as the electrochemical sensor is less accurate for the first 30 minutes that it is plugged in. The Halimeter does not have to be switched on during this 30 minute warm up period, nor is it necessary to wait another 30 minutes before using the Halimeter if you momentarily unplug it, move it to another location, and plug it in again.

3.  We recommend that the patient be seated in a dental chair. The patient should be seated sideways on the chair with the arm of the chair raised or otherwise retracted. The patient should be facing the front of the Halimeter. The operator should be positioned to view and manipulate the adjustments on both the penwriter and the Halimeter.

4.  The patient is instructed to close his/her mouth and keep his/her lips sealed in preparation for sampling mouth air. A timer is set for 3 minutes. During these 3 minutes the operator should perform the tasks as detailed in steps 5-14.

5.  Assemble on a work surface four flexible straws (7 5/8″ x 15/64″ dia. {194 x 6 mm} Glad), two Ziplock bags (6 5/8″ x 5 7/8″{168 x 149 mm}Glad), a 2″ (51 mm) strip of orthodontic tray wax (Hygienic), and a pair of scissors.

6.  Switch on the Halimeter and adjust digital readout to “000” ppb using the ZERO control.

7.  Cut a 2″ (51 mm) section off one of the straws. Wrap a piece of ortho tray wax around this section and an intact straw, so that the orifice of the intact straw protrudes 1 1/2″ (38 mm) beyond the orifice of the 2″ (51 mm) section of straw. This configuration becomes the mouth air sampling straw.

8. Cut a small corner off each of the two Ziplock bags. Insert one end of each of the two remaining straws into each bag through the cut corner hole. The bag should be zip locked and deflated.

9.  Insert the short end of the mouth air sampling straw into the inlet of the Halimeter. Turn on the penwriter.

10.  Set the penwriter INPUT to 0.5 V, CHART SPEED to 2 cm/min, and ZERO to STBY. Lower the pen to contact the paper.

11.  Adjust the ZERO knob of the penwriter so that the pen falls exactly upon the far right centimeter line on the chart paper. This line represents zero parts per billion (ppb) of volatile sulfur compounds (VSC).

12.  Direct the free end of the mouth sample straw away from the operator and the patient.

13.  Switch the penwriter into the record mode (switch from STBY to REC) and adjust the ZERO control on the Halimeter until the pen scribes a straight line over the far right line on the chart paper (the zero line). You have now zeroed the Halimeter and recorder to ambient air. Check the digital window on the Halimeter to see that it is reading “000” ± 5 ppb. This digital reading may fluctuate, and the peak readings will appear and disappear quickly, which is why many offices use the penwriter. Of course, the penwriter also provides a permanent patient record.

14.  Once the penwriter is zeroed correctly in relation to the Halimeter, you need only observe the position of the pen on the chart paper when zeroing to ambient air or recording. You must zero the Halimeter before each recording by adjusting the ZERO control on the Halimeter to position the pen on zero (the far right line) on the chart paper. You should periodically check the digital screen on the Halimeter to check that zero on the penwriter corresponds to zero on the Halimeter.

Recording VSCm(mouth air VSC)

15.  With the penwriter on and recording, direct the mouth sample straw toward the patient.

16.  Tell the patient that you are going to explain what (s)he is to do, but that (s)he should continue breathing through the nose with lips sealed until you are ready to start recording. If the patient does not understand, (s)he should raise a hand so you can repeat the instruction. The patient must not talk or open his/her mouth. If (s)he does, you will have to begin the 3 minute incubation period all over again.

17.  Tell the patient that when you say “go” (s)he should take a deep breath in through the nose.

18.  With breath held, (s)he should lean forward and seal his/her lips around the wax bead around the straw. (S)He should not blow out or in but simply hold his/her breath for the approximately 10-15 seconds it takes to make the recording. The open end of the intact straw should be located in the center of the mouth. The patient should avoid touching the open end of the straw with the lips, tongue, or cheeks. The 2″ (51 mm) section of straw held in position by the wax acts as a vent to equalize pressure in the mouth as the mouth air sample is drawn into the Halimeter.

19.  When the timer sounds the end of 3 minutes, tell the patient to “go” and watch that (s)he executes the maneuver properly.

20.   Observe the recording of the penwriter, or the Halimeter’s digital display. A peak reading should be obtained within 2-5 seconds. After about 10-15 seconds, tell the patient to pull away from the straw.

21.  Allow the recorder pen to return to the “zero” line before making the next recording.

22.  For maximum accuracy, incubation and Halimeter sampling (steps 15-21) should be performed three times, and the average peak reading calculated.

Recording VSCn(nose air VSC)

23.  Reset the timer for 2 minutes and have the patient pinch his/her nose closed and breathe through the mouth.

24.  When the timer sounds, take one of the plastic bags with a straw protruding from the corner, and insert the free end of the straw into one of the patient’s nostrils. The patient continues to pinch the nose closed and blows a small quantity of air into the bag.

25.  Then, switch nostrils and repeat until the bag is one half full.

26.  The operator holds the edges of the hole in the bag tightly around the straw with his/her finger or a rubber band to avoid losing the sample. Tape may also be used.

27.  Then, use the scissors to cut off the end of the straw that was inserted into the patient’s nostrils, and feed the freshly cut end of the straw into the inlet port of the Halimeter. Observe the deflection of the pen, or the Halimeter’s digital display and remove the straw from the inlet before the bag is fully deflated.

28.  Discard the bag and straw.

Recording VSCl(lung air VSC)

29.  A sample of alveolar air is obtained by having the patient breathe normally through the mouth for 30 seconds. Then, ask the patient to hold his/her breath at the end of expiration.

30.  Insert the free end of the straw protruding from the remaining bag into the mouth, and instruct the patient to blow out the remaining air from his/her lungs. As the patient forces out the remaining air, the bag should just barely fill. In other words, you should capture the last little bit of air the patient can force out of his/her lungs.

31.  Quickly remove the straw from the mouth, cut off the free end of the straw with scissors and insert the cut end of the straw into the inlet port of the Halimeter. Again, observe the deflection of the pen, or the Halimeter’s digital display.

32.  The measurements indicate the relative amounts of VSC generated from mouth air, nose air, and lung air. This information is helpful in determining the source of malodor.