Breath testing is a valuable tool for healthcare providers to identify gut microbiome-related conditions by analyzing fermented gases in a patient's breath. The Trio-Smart breath test, in particular, measures hydrogen, methane, and hydrogen sulfide levels after consuming lactulose or glucose, aiding in the diagnosis of Small Intestinal Bacterial Overgrowth (SIBO), Intestinal Methanogenic Overgrowth (IMO), and Intestinal Sulfide Overproduction (ISO). Abnormal gas levels indicate microbial overgrowth, linking specific gases to distinct symptoms and conditions.
Understanding Breath Testing
Breath testing evaluates gases produced in the gut microbiome by analyzing exhaled breath samples. After ingesting a sugar substrate, gut bacteria consume the sugar and release gases. Overgrowth leads to excess gas production, detectable through the test. Bloating is a prominent symptom of SIBO. Breath testing assesses treatment efficacy and identifies the root cause of symptoms.
The Three Primary Fermented Gases
The three primary fermented gases found in the gut microbiome are hydrogen, methane, and hydrogen sulfide.
- Hydrogen: Produced when certain bacteria in the small intestine consume sugars, with elevated levels often indicating SIBO. Symptoms of SIBO can include bloating, abdominal pain, gas, abdominal distension, indigestion, constipation, and diarrhea.
- Methane: Produced when archaea consume hydrogen, with elevated levels indicating IMO and often associated with constipation.
- Hydrogen Sulfide: Produced when hydrogen sulfide-producing organisms consume hydrogen, with elevated levels indicating ISO and associated with diarrhea. Emerging research indicates that the most telling symptom of ISO is diarrhea, with higher hydrogen sulfide concentrations correlating strongly with an increased prevalence and severity of diarrhea in many patients.
Interpreting Test Results
Breath test reports typically include a graph showing gas levels over time, indicating any abnormal elevations.
- Hydrogen: The threshold is calculated by adding 20 ppm to the baseline. Hydrogen levels are considered elevated when there is a rise of 20 ppm or more from the baseline within the first 90 minutes of the test. The “baseline” is determined from your breath sample taken before the ingestion of the sugar solution.
- Methane: The threshold is always 10 ppm. Levels of 10 ppm or more at any point during the test are considered abnormal.
- Hydrogen Sulfide: The threshold is always 3 ppm. Hydrogen sulfide levels are considered elevated when they are 3 ppm or higher at any point during the test.
Hydrogen, methane, and hydrogen sulfide interact in a complex way, with a balance-counterbalance effect between methane and hydrogen sulfide. Hydrogen sulfide is strongly associated with diarrhea, with the level correlating with the degree of diarrhea. Measuring hydrogen and methane can offer a partial story about a patient’s GI symptoms.
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Preparing for the Trio-Smart Breath Test
Preparation is essential for accurate SIBO breath test results. The process includes a prep diet, fasting period, and the breath test itself.
The Preparation Diet
A restricted preparation diet should be followed for 12-24 hours before testing, focusing on plain, simple, low-fiber foods. The goal is to avoid foods high in starch, sugars, and fiber.
Foods to Include:
- Protein: Any meat, fish, eggs, or plain or firm (not silken) tofu, or seitan. Any meat ingested must be made without any added sugars/brines/cures/etc. to avoid contaminating the prep diet. Avoid meats like deli-meat, lox, and pre-prepared meats that have any other herbs and spices besides salt and pepper. The sashimi fish is fine on the prep diet, when eaten alone and without sauce.
- Simple Carbohydrates: White rice and white potato. If rice causes bloating, okay to have plain oatmeal or squash. The only grain acceptable on the prep diet is plain, white rice. Other rice/grains have a higher level of fiber and macromolecules that SIBO bacteria like to eat. The rice in Nigiri is usually made with sugar-based binders to make it stick together better, and thus should be avoided on the prep diet. The only exception is home-made Nigiri with steamed white rice and no sauces.
- Seasonings: Limit to oil, salt, and pepper. Using small amounts of olive oil for cooking is usually fine during your breath test prep.
Foods to Avoid:
- Fermentable foods such as complex carbohydrates on the day prior to testing. Complex carbohydrates include beans, nuts, seeds, fruits, vegetables. The SIBO prep diet specifically cuts out plant products and sugars in order to starve the bacteria for a day prior to taking the test, which will give you the most accurate results.
Important Considerations:
- If you do not eat grains, for example, do not consume the rice. If you do not eat eggs, then do not start just for this diet.
- If you consume meat broth for the prep diet, it must be made from ONLY the meat. There cannot be any bone or cartilage included, and it cannot have any vegetables or herbs (aside from salt and pepper) in it.
- Any substitutions can give inaccurate test results.
The Fasting Period
Generally, a complete fast for at least 12 hours before the SIBO test is necessary, meaning no food or beverages, not even gum. The fasting period is crucial for clearing the digestive tract before the test. Typically, it’s best to eat lightly from the white diet the day before (aim for at least 12 hours before the fasting window). For example, fast from 7PM to 7AM the next morning. Start fasting timer after your last bite of food.
Medications and Other Substances
- Stop taking all non-essential medications, supplements, and pro-biotics during the prep diet. This includes over the counter pain medications, allergy medications, and antacids. If you don’t know what medication is considered essential, consult your prescribing physician.
- It’s perfectly fine to brush your teeth, just be sure not to swallow toothpaste. Similarly, don’t chew any gum or suck on mints before your breath test.
- Most importantly, do not smoke. If you are a smoker, of tobacco or cannabis, there is no recommendation to stop use during the prep diet. However, do not smoke anything for at least one hour prior to taking the breath test, or during the time of the test (4 hours total). If you ingest cannabis in edible form, it must be avoided during the prep diet. Smokeless tobacco (chew) should be avoided during the prep diet and prior to the test as well.
Taking the Test
The SIBO breath test involves a 24-48 hour prep diet (the length depends on your doctor’s recommendation), a 12 hour fast prior to the test, and a 3 hour breath test (once every 20 minutes) after drinking a solution of lactulose. Once you’ve completed your SIBO test preparation, it’s time to take it.
Here’s the process you will follow for a QuinTron breath test:
- Mix the drink included with your test kit, following the directions in your kit unless your healthcare provider requests you to do something different-mixing the drink with plain water.
- Follow the instructions on your test.
- Avoid activities like exercise, eating, or doing other things while you test. View it as a chance to take a break and relax.
- Label each vial according to the breath test instructions.
Understanding Trio-Smart Breath Test Results
After analysis, you'll receive a report detailing gas levels at 15-minute intervals. Understanding the thresholds is crucial for interpreting the results.
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Gas Level Thresholds
- Hydrogen: Elevated when there is a rise of 20 ppm or more from the baseline within the first 90 minutes of the test.
- Methane: Elevated when levels are 10 ppm or higher at any point during the test.
- Hydrogen Sulfide: Elevated when levels are 3 ppm or higher at any point during the test.
Interactions Between Gases
It’s important to note that these gases and the microbes that produce them don’t operate in isolation. Hydrogen is the common fuel-produced by bacteria fermenting the sugars and fibers in your gut-and it can be consumed by other organisms to produce either methane or hydrogen sulfide. For example, if hydrogen is being consumed rapidly by methanogens (like the archaea associated with IMO) hydrogen levels may appear low, even if there is an overgrowth problem. That’s one of the major reasons why it’s so important to test for all three gases and then discuss your findings with your healthcare provider(s) to ensure proper assessment of your specific results and conditions.
Trio-Smart in Action: Examples of Possible Cases
- Example 1: Sofia experiences bloating and a mix of constipation and diarrhea. Her Trio-Smart results show a rise in hydrogen gas of 25 ppm within 45 minutes of the start of her test, while methane and hydrogen sulfide remain within normal limits.
- Example 2: Jamal has a long history of constipation and hard, pellet-like stools. His Trio-Smart test reveals a methane level of 15 ppm at baseline and remains elevated throughout, while his hydrogen and hydrogen sulfide levels remain stable and within normal limits.
- Example 3: Liam has chronic loose stools and complains of excessive gas and fatigue. His hydrogen sulfide levels are consistently above 4 ppm, while other gases are normal. This pattern suggests that Liam may have ISO, so his doctor recommends antibiotic treatment and long-term management of his symptoms with Pepto Bismol and a low-sulfur diet.
The Importance of Retesting
As you progress through your gut health journey, you may find it beneficial to retest your gas levels in the future. Retesting can help you and your provider(s) assess whether gas levels have returned to normal and can help confirm whether your treatment and management plan is working.
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