EBT manuscript for IEEE special issue on exhaled breath 1

Development of an Individual Device for

Exhaled Breath Temperature Measurement
Todor A. Popov, Tanya Z Kralimarkova, Christo T. Tzachev,
Stefan S. Dunev, Vasil D. Dimitrov, Jas Gill*

Clinic of Allergy & Asthma Sofia; *Delmedica Investments Singapore

and reactions and have made temperature measurement an

Abstract—Different thermometers have been constructed over integral part of routine patient examination [1].
the decades to measure the temperature of the body to help
Historically, temperature measurement has been used to assess
detect and monitor morbid states. They yield slightly different
fever and its course as a diagnostic and prognostic tool in
estimates of the core body temperature depending on the
infectious diseases. Modern day anesthesia uses controlled
proximity of the measurement site to the internal milieu of the
hypothermia to allow prolonged surgical interventions of vital
organism, the principle of temperature assessment and the
organs requiring accurate core body temperature monitoring
specific characteristics of the gauging devices. Evaluation of
[2]. For practical purposes thermometry at traditional body
the exhaled breath temperature (EBT) has been recently
sites is performed giving estimates of the actual core
suggested as a new method to detect inflammatory processes in
temperature with reasonable degree of approximation [3].
the conducting airways due to changes in the blood flow
Thus, rectal temperature is considered most representative of
perfusion of their walls and adjacent structures. While the first
the core body temperature, but its measurement is disliked by
reported EBT experiments required sealed laboratory
patients and carries the risk of bacterial contamination. Oral
environment and sophisticated equipment, we designed a
temperature is generally 0.5ºC less than the rectal temperature
simple hand-held instrument for EBT measurement and proven
and is more prone to influences from the ambient environment.
its precision, reproducibility and validity in subjects with
Core temperature can be estimated with reasonable accuracy at
asthma. We now describe the construction principles of our
the axilla (armpit) and by a catheter in the bladder. Because
instrument, the procedure to test the fitness for purpose of the
the eardrum is close to the carotid artery and the
separate units and the novel features of the newest prototypes
hypothalamus, tympanic membrane temperature, usually
outfitted with microprocessor and memory. We also outline
referred to as otic temperature, is another reliable estimate of
the potential clinical applications of an individual device for
core temperature and is often used as reference for other sites.
EBT measurement.
All other conditions of measurement being equal, the
Index Terms—Core body temperature, thermometry, exhaled
differences between the temperature values at specific body
breath temperature, airway inflammation, clinical applications.
sites are due to the influence of the “core-to-surface” interface.
While this may be considered a confounding factor from point
I. INTRODUCTION
of view of evaluation of the “true” core temperature,
HE human organism needs to maintain the temperature of differences due to the core-to-surface gradient may present an
Titsrangevital organs (core body temperature) within a narrow
to allow essential enzymatic reactions to occur.
opportunity to get useful information about pathology
associated with the interface itself.
Changes outside this range are indicative of pathologic states
This type of reasoning became the starting point for attempts
to measure exhaled breath temperature (EBT). The deep
Manuscript received February 15, 2008. Much of this work was supported
by a research grant from Delmedica Investments in Singapore. structures of the lung typically have temperature representative
T. A. Popov is with the Clinic of Allergy and Asthma, Medical University, of the body core. It is determined by the blood flowing along
Sofia, 1431, Bulgaria. Phone: +359-2-9230297; Fax: +359-2-9230621; e- the rich vascular network of the alveoli. During the breathing
mail: ted.popov@gmail.com. cycle gases but also thermal energy are exchanged between the
T. Z. Kralimarkova s with is with the Clinic of Allergy and Asthma, Clinic
of Allergy and Asthma, Medical University, Sofia, 1431, Bulgaria. (e-mail:
inner milieu of the organism and the ambient environment.
tkralimarkova@gmail.com). The temperature of the inhaled air is tempered during its flow
C. T. Tzachev is with the Faculty of Pharmacy, Medical University, Sofia, in and out of the branching airways, which have a separate
1431, Bulgaria (e-mail: christo_tzachev@hotmail.com). system of blood supply. As blood is the main carrier of thermal
S. S. Dunev is retired construction engineer of electromedical equipment
(e-mail: sdunev@abv.bg).
energy maintaining the core body temperature, processes that
V. D. Dimitrov is with the Clinic of Allergy and Asthma, Clinic of Allergy would modify its flow within the airway walls might reflect on
and Asthma, Medical University, Sofia, 1431, Bulgaria. (e-mail: the temperature of the outgoing air, i.e. EBT. High precision
vas_dim48@alexandrovska-hospital.bg). gauging devices may pick this signal and give ground for
J. Gill is engineer with Delmedica Investments Singapore (e-mail:
clinical inferences.
jas.gill@delmedicainvestments.com).
 EBT manuscript for IEEE special issue on exhaled breath 2

We believed that the capacity of the thermoinsulated

Thus, some 8 years ago, Paredy and colleagues in London [4]
chamber to preserve heat from spilling into the ambient
and Piacentini and colleagues in Verona [5] started measuring
environment was a key to getting an accurate estimate of the
the exhaled breath temperature (EBT) of their asthmatic
temperature of the air exhaled by the subject. We used for our
patients. Their reasoning was that tissue vascularization and
first prototypes 0.5 L vacuum flasks (known as Dewar’s
temperature increase are inherent to the process of
vessels) available on the market as containers to preserve the
inflammation, which is nowadays believed to be the hallmark
temperature of beverages or thermoses (Figure 2) [9].
of asthma. Both teams used fast reacting thermocouples in
front of the mouths of the tested subjects and analyzed the rise
in temperature during single breath maneuvers on the screen of
computers. This required sealed laboratory environment with
constant temperature, minimal air movement and subject
training to allow the record of comparable exhaled temperature
curves. While the London team considered the rate of
increase of the exhaled breath temperature as indicative of
asthma [4, 6], the researchers in Verona made a series of
experiments proving that the top of the plateau of the exhaled
breath temperature curve is the variable, distinguishing
asthmatics from healthy controls [7, 8].
Some 10 years ago we also began work on EBT
measurement using a simple portable device, which makes the
evaluation process less dependent on ambient factors and
allows individual home measurements in patients with diseases
requiring daily / frequent control.
II. BASIC DESIGN
A. Designing of the first prototypes Figure 2. First prototype of EBT device.
The idea we developed when constructing our EBT device We needed to select from the existing diversity of models
was to accumulate the thermal energy of the exhaled air of a the ones with best capacity to preserve heat, so we devised a
tested subject into an insulated vessel containing a metal core protocol to test their thermal resistance (R). It consisted of
with high heat capacity (Figure 1): placing a resistor (heater) in the lower part of Dewar's vessel
and connecting it to external stabilized 12V power (P) source,
emitting 0,5 Watt (W) heat inside the thermos (input
power,PIN = constant = 0,5 W). In the upper part of the flask,
a temperature sensor was placed and connected to a
temperature reading device (thermometer). The passage of
connecting wires through the thermos cap was sealed.
Switching on of the heater initiated temperature rise in the
thermos. Convection of heat from inside to outside (output
power,POUT) proportional to temperature difference (TIN -
TOUT) occurred:
POUT = (TIN - TOUT) / R,
where R is the thermal insulation resistance of the thermos
TIN rose in time to reach a maximum value TIN MAX, when the
output power became equal to consumed power:
POUT MAX = PIN = (TIN MAX - TOUT) / R.
With PIN constant = 0,5 W, the difference TIN MAX - TOUT [K
(kelvins)] was an indicator of the insulation of the thermos:
R = 2 * (TIN MAX - TOUT) [K / W]
Example: If TIN MAX - TOUT = 10 K, then R = 2 * 10 = 20 K/W.
Figure 1. Schematic of the concept of a portable EBT As it turned out, thermoses from the same make and model
measuring device. yielded a wide range of values for R, with less than 10%
 EBT manuscript for IEEE special issue on exhaled breath 3

showing good insulating properties, making them fit for use as

EBT measurement devices.

B. Generations of EBT measurement devices

The first experiments to prove the feasibility of EBT

measurement in subjects with inflammatory airway disease
were made with only 2 devices giving identical readings (first
generation devices) to minimize any bias due to inter-device
variability (Figure 2). As the aim of the experiments to follow
was to check the feasibility of making daily measurements at
the homes of asthmatics in order to monitor the control of their
inflammatory airway disease [10], we had to manufacture a
bigger batch of individual instruments with slight change in the
overall design (e.g. the volume of the thermoinsulated chamber
was reduced to 0.3 L) to give to the patients (second
generation devices). We needed, therefore, an additional
procedure for testing of the relative accuracy of the next 40 Figure 3. Front and hind photographs of a third generation
devices we built to ensure that the values measured by each EBT measuring device with indication of components.
one fall within a very narrow range.
Each EBT device was tested under the same ambient III. APPLICABILITY OF THE EBT DEVICE IN MEDICINE
conditions in a sealed room with fixed temperature and no
movement of people. Air with constant temperature and One of the crucial questions we needed to answer at the
constant flow was passed through each device for 10 min. The beginning of our work, was whether EBT is just another
temperature values at the 10th minute for each device were surrogate measure of core body temperature, or whether it also
pooled together to calculate the average temperature for the captures the signal emitted by the airways. Pooling together
whole series. Devices deviating by more than 0.15 K were 132 EBT measurements of healthy subjects and asthmatics, we
excluded from the series. did not find meaningful correlation between EBT and otic
temperature, while there was a highly significant correlation
Using the first and second generations of EBT measurement between otic and axillary temperatures (Figure 4) [9].
devices was acceptable on the part of the tested subjects, but
still lacked the level of convenience to make it usable for
larger scale trials and eventually for everyday clinical practice.
Thus investigator and tested subjects had to check the
temperature reader of the EBT device every minute to identify
the end of the measurement (reaching a plateau, i.e. two
identical readings 1 minute apart). In addition to high precision
and reliability, we had to consider putting in electronics to
signal the end of the evaluation, to memorize the measured Figure 4. There was a highly significant correlation between otic and
value, to identify the tested subject and to document the date axillary temperatures, and no correlation between otic and EBT.
and time of the measurement. We reckoned also that
monitoring the progress of the attempt and analyzing the curve Another important issue was whether moderate changes in
of the measurement on the screen of a computer would add the ambient conditions would bias measurement with the EBT
extra value for physicians and investigators. With the help of device. Multiple regression analysis of the same 132
professionals from Philips Singapore we have now at our measurements made with EBT as dependent variable and room
disposal for testing a batch of devices offering simplicity of temperature (values on separate days in the range 18–25°C),
use combined electronic prompt and ergonomic design (Figure atmospheric pressure (range 954–982 hPa) and humidity
3). However, one of the most important tasks ahead of us now (ranges 22–72%) as independent variables, did not pick any of
would be to shorten the time of measurement from typically 5 the ambient conditions as significant determinants [9].
to 7 minutes to less then 3 minutes. Presently we are exploring Most studies on EBT so far have been done in asthmatic
the possibility to predict with reasonable degree of precision patients and have suggested the utility of this approach to
the final result of the temperature measurement ahead of time assess non-invasively changes in the degree of airway
[11]. inflammation [4-10]. Our portable device makes this method
much more applicable in everyday clinical practice as it makes
possible individual measurements possible in the home of
 EBT manuscript for IEEE special issue on exhaled breath 4

those suffering. The option with the newest third generation

devices to have a long list of measurements accessible to the
treating physicians could make decision making about
treatment modalities more objective.
EBT measurement appears to hold promise also in other
lung diseases. There is a report that EBT is shifting
downwards in patients with chronic obstructive pulmonary
disease, in whom airways and pertaining vasculature are
reduced [12]. We have preliminary yet unpublished data of
increased EBT (but not axillary temperature) in cases with
viral infections, tuberculosis and bronchopneumonia.

IV. CONCLUSION
The temperature of the exhaled breath turns out to be an
unexplored area on the map of human physiology and disease.
There is a vast territory to systematically cover in order to
figure out the utility of this simple and cheap approach. Once
data start poring in, applications may become evident also in
other medical fields.

REFERENCES
[1] D.L. Kasper, E.Braunwald, A.S. Fauci, S.L. Hauser, D.L.Longo, J.L.
Jameson. Harrison's Principles of Internal Medicine. New York:
McGraw-Hill, 2005.
[2] S.R. Insler, D.I. Sessler. Perioperative thermoregulation and
temperature monitoring. Anesthesiology Clin 24 (2006) 823–837.
[3] M. Sund-Levander, C. Forsberg, L.K. Wahren. Normal oral, rectal,
tympanic and axillary body temperature in adult men and women: a
systematic literature review. Scand J Caring Sci 2002;16(2):122–8.
[4] P.Paredi, S.A. Kharitonov, P.J. Barnes. Faster rise of EBT in asthma:
a novel marker of airway inflammation? Am J Respir Crit Care Med
2002; 165: 181–184.
[5] G.L. Piacentini, A. Bodini, L. Zerman, et al. Relationship between
exhaled air temperature and exhaled nitric oxide in childhood asthma.
Eur Respir J 2002; 20: 108–111.
[6] P. Paredi, S.A. Kharitonov, P.J. Barnes. Correlation of exhaled breath
temperature with bronchial blood flow in asthma. Respiratory
Research 2005; 6, 15: 1-10.
[7] G.L. Piacentini, D. Peroni, E. Crestani, F. Zardini, A. Bodini, S.
Costellaw, A.L. Boner. Exhaled air temperature in asthma: methods
and relationship with markers of disease. Clin Exper Allergy 2007; 37:
415–419.
[8] M. Pifferi, V. Ragazzo, A. Previti, G. Pioggia, M. Ferro, P. Macchia,
G.L. Piacentini, A.L. Boner. Exhaled air temperature in asthmatic
children: a mathematical evaluation. Pediatr Allergy Immunol 2008,
online: Mar 10 2008; DOI: 10.1111/j.1399-3038.2008.00742.x.
[9] T.A. Popov, S. Dunev, T.Z. Kralimarkova, S. Kraeva, L.M. DuBuske.
Evaluation of a simple, potentially individual device for exhaled
breath temperature measurement. Respiratory Medicine, 2007; 101:
2044-2050.
[10] T. Kralimarkova, C. Lazarova, V. Dimitrov, T.A. Popov. Ability of an
individual device for measurement of the temperature of exhaled
breath to detect changes in patients recovering from mild
exacerbations of asthma. ERS Berlin 2008: 186s.
[11] T.A. Popov, T.Z. Kralimarkova, C.T .Tzachev, V.D. Dimitrov, K.K
.Mun, J. Gill. Exhaled breath temperature measurement made easy.
Pediatr Allergy Immunol 2008, online: Nov 10 2008; DOI:
10.1111/j.1399-3038.2008.00837.x.
[12] P. Paredi, G. Caramori, D. Cramer, S. Ward, A. Ciaccia, A. Papi, S.A.
Kharitonov, P.J. Barnes. Slower rise of exhaled breath temperature in
chronic obstructive pulmonary disease. Eur Respir J. 2003
Mar;21(3):439-43.