Needing Info on Neuro Breath

[Mourkoth]

I asked a Neuro Sergeon about this bad breath. This terrible breath seems to even smell similar. I said that it was terrrible even after repeated episodes of oral care. We've tried everything. The best for decreasing the smell and also aids in the repair of oral trauma is a 1:1:1 ratio mixture of NS, Peroxide and Cepecol. Anyway this doctor explained the breath problem. I don't know if he was giving me a load of BS but, his story sounds plausable. He said that it was an enzyme given off by trauma or injury to the brain. This enzyme's effect was like the "fruity" breath given off by diabetics. Only this enzyme produces rancid breath. I however, haven't found data to back up his claims.

[gwenith, BSN, RN]

I too, have never seen it mentioned in texts or literature (although that does not mean there is not an article somewhere). It is a distinctive and unpleasant smell and does not seem to be associated with good oral care since nothing seems to make it better.

Having said that Neuro patients can be extremely difficult to perform good oral care on as they can and will bite down or spasm when stimulate the mouth.

[Keysnurse2008]

I am no expert on the origin of neuro breath, but think about the patients who do have "neuro breath". Usually these patients have had a hemorrhagic stroke ( sah etc etc ).

So add blood in the cranial vault, intubation with the mouth wide open of course (to spread the aroma ), then the elevated ICP which of course causes congestion.

What happens when your sinuses are irritated/congested?Lots of copious nasty secretions, add a lil aspiration pneumonia, add possibly a lil csf leak trickling down the back of the throat.

The blood is still in the cranial vault too. Mix well, and poof- neuro breath!

Secretions pool atop the ETT.

It is probably caused by many things.

But...it is NOT your average ICU intubated bad breath. Neuro breath is far nastier. You can do the VAP mouth care q1hr and PRN, but it won't mask that smell. It smells like a rat crawled in there and like decayed at times.

Id be very interested if anyone does actually have evidence-based documentation on cause of neuro breath.

[1Tulip]

You might be right TNN. But unless you have some data or a reference, I'm putting my money on the usual causes of bad-mouth-syndrome in pts (intubated or not) who can't clear their own secretions.

One thing that may set neuro patients up (and you'll have to forgive me 'cause it's been a long time since I worked ICU) but don't we tend to keep these pts dry? I believe that fluid balance can have a huge effect on mucous membrane status. Also, you have to look at the meds they might be on. Any drug that has anti-cholinergic actions (and a lot of drugs are "dirty" in the sense that they can act at multiple receptor systems) will alter the saliva a LOT... drying it up. (I'm currently using DuoNeb which has atropine in it and I can TELL you it makes the inside of my mouth like it was full of glue.)

So, I think that neuro breath is just bad-mouth-syndrome in spades. I am not sure what your VAP mouth care protocol is. But I've taken over pts who have had "mouth care" (and I'm talking about taking over from some fine nurses that I do respect.) but then find a protienacious filmy stuff on the mucous membranes. It can just look like dry membranes, but there is a layer of stuff there and it's hard to remove. But must be removed. Definitely causes bacteria laden oro-pharynx.

[gwenith, BSN, RN]

We don't keep them dry anymore but one explanation for this smell can simply be pooling of secretions above the cuff. Usually intubated patients will have come pooling at the back of the throat but considering the amount of saliva you generate per day this is minimal. They will also part swallow (yeah I know that the swallow is incomplete but they do part swallow) if not clearing then moving the saliva out and away from the area above the cuff. Neuro patients who have interrupted swallow/gag mechanisms will not do this. I am not talking here about pooling in the back of the throat where it can be suctioned by a Yankhauer sucker I am talking about above the cuff of the ETT - too far down to REALLY get to with suction unless you have a Hi-Lo Evac tube,

http://www.nellcor.com/educ/List.aspx?S1=QUI&S2=AIR

It would be interesting to see research on this topic.

[1Tulip]

While we're tallking about this... I would like to pick your minds a bit. I'd appreciate your feedback.

I went to a poster session put on by an ICU CNS on VAP. She and I agreed on the importance of mouth care and I picked up some good tips from her on how they do it. (I work on a neuroscience, non-ICU unit). But one of their anti-VAP policies is to keep the HOB up at least 30 degrees. Makes sense, from that stand point. Obviously when they are flat, gravity will do what gravity will do and contaminated secretions will go down.

But I see a problem. You can't effectively turn a patient when the bed is gatched. Now... I know we "tilt" our patients a bit and shove pillows under their shoulder or back. And that helps prevent some sacral skin break down. (Especially if you're using specialty mattresses.) But... I don't think it does diddle-squat to prevent atlectasis... which along with portal of entry (ET tubes) and micro-aspiration, have got to contribute to pneumonia.

Back in the old days I used to reeeeally turn my patients on their sides. By that I mean, a line drawn between the pt's scapulae would pretty much be perpendicular to the mattress. I put the top leg, bent and forward, so that the weight of the leg helped hold the pt. in position. I put a pillow between the legs to promote comfort. I paid good attention to spine allignment and made sure the head was adequately supported. And you know what???? Drool and mouth secretions went onto the pillows, not down the pts' airways. (I used chux to catch the liquid.) But the good thing was the patient's entire back and buttocks were exposed to air. And the bases of the lungs were able to be expanded without the pressure of the mattress and the weight of the patient's body.

It took a little imagination to re-arrange wires and tubes, and if the pt. was picking at things, I had to reconfigure restraints. But it worked. This is not a good position if you're doing stuff to the patient. But for the quiescent times, I believe we should consider this as a legitimate technique to prevent aspiration and atelectasis.

I'm finding it a tough sell. Wondering if you might have thoughts.

Oh, and it didn't take two people to effect for most of my patients. I could do it by myself. (If they were fighting me... it didn't work, but that was rarely the case.)

[Keysnurse2008]

A lot of the patients that are in the Neuro ICU are still kept pretty dry. Hence why we utilize mannitol and hot salts on them (3%). We try to keep their NAlevel around 150.....so when they are that hypernatremic, everything is drying up!

I tend to think of it being a combo of things too, and you could be correct about the secretions pooling above the ETT cuff. But again, I have worked in different ICU's, and neuro patients/tbi's, it is a far different "aroma", and I'd love to know the evidence-based answer as well.

[Keysnurse2008]

This sounds plausible.I mean the body has numerous events that cause a cascade of events like the enzyme he is describing. Think about lactic acid????...when....do we see those levels high?HIT......what causes it.....the bodies "response"...correct???So.....I think your neurosugeon may be correct.......bc neuro breath....no matter how aggressively you do mouth care ......is rancid!!!!!!!!!!!!!!!!!!!It smells as though a dead animalcrawled up there and died....totallly different than just your long term vented bad mouth smell.So....I buy his theory.Id love to know what this enzymatic reaction is called...other than us just calling it neuro breath though.Good insight though!!!!!!!!!!!!!Thanks!!!!!!!!!!!!!!!!!

[lgjackson]

I have often noticed that many neuro patients are mouth breathers. When checking those pupils for reaction, shine that flashlight in the roof of your patient's mouth. I just recently found a patient with 1/4" crust of dried mucous there and believe me, it really stunk when trying to dig it out !! I think some nurses think that just swabbing out the mouth is enough, but these mouth breathers really need major oral care, especially in the roof of the mouth !!

[gwenith, BSN, RN]

I have often noticed that many neuro patients are mouth breathers. When checking those pupils for reaction, shine that flashlight in the roof of your patient's mouth. I just recently found a patient with 1/4" crust of dried mucous there and believe me, it really stunk when trying to dig it out !! I think some nurses think that just swabbing out the mouth is enough, but these mouth breathers really need major oral care, especially in the roof of the mouth !!

Neuro breath as described by other members here is a bit different to that, although I will concede that this can and does happen. The actual "smell" is VERY distinctive and seems to correlate with the degree of brain injury

[sirI, MSN, APRN, NP]

I found a link here at Allnurses.com about likes and dislikes in the Neuro ICU and this was briefly discussed.

[Lucymeow]

Hey TopKAt. I happen to agree that Neuro patients seem to have a distinctly odiferous smell to them. I don't think it has anything to do w/ poor oral care or the use of meds such as mannitol. In my ICU they use mannitol and IRP on septic patients and they do not seem to develop the unique smell of "neuro breath".