Carbon Monoxide (CO) Monitoring for

Smoking Management:
A brief guide for staff
Statewide Respiratory Clinical Network
March 2021
Carbon Monoxide (CO) Monitoring for Smoking Management: A brief guide for staff
Statewide Respiratory Clinical Network

Published by the State of Queensland (Queensland Health), March 2021

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Contents

1. An introduction to carbon monoxide (CO) monitoring ............................. 4

1.1 What is CO monitoring? ................................................................................4
1.2 What is carbon monoxide (CO)?....................................................................4
1.3 What effect does CO have on the body? .......................................................4
1.4 Why use a CO monitoring device with patients / clients? ...............................4
2. Equipment and resources ........................................................................... 5
2.1 What equipment is required to use the Smokerlyzer® device? ......................5
3. Device operation ........................................................................................... 6
3.1 Multiperson use Smokerlyzer® models..........................................................6
3.2 Single person use Smokerlyzer® model ........................................................7
3.3 Interpreting the CO monitoring results ...........................................................7
4. Infection control ........................................................................................... 8
4.1 How do I clean the device?............................................................................8
4.2 What infection control practices are required in routine care? ........................8
4.3 How often do I need to change the mouthpieces? .........................................9
4.4 Why is the D-piece™ re-useable? .................................................................9
4.5 COVID Precautions .......................................................................................9
5. Associated equipment costs .................................................................... 10
5.1 Initial purchase and ongoing operation costs ...............................................10
5.2 Calibration cost and frequency ....................................................................10
5.3 How much would CO monitoring mouthpieces cost for a month? ................11
6. More information ........................................................................................ 11
7. Further reading .......................................................................................... 11
8. Version Control and Review History ........................................................ 12

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1. An introduction to carbon monoxide (CO) monitoring

1.1 What is CO monitoring?

A hand-held carbon monoxide monitor, such as a Smokerlyzer®, is a device
used to measure the level of carbon monoxide (CO) in the body via a breath
test.
The monitor measures the level of CO in a person’s breath, which indirectly
measures the level in the blood. The monitor can be used to measure CO
levels in adults, adolescents and unborn babies and can provide a reading
for both smokers and passive smokers.

1.2 What is carbon monoxide (CO)?

CO is a colourless and odourless gas that is created from combustion or the burning of organic matter.
Sources of CO include smoke from a cigarette, joint, bong, fire or BBQ, exhaust fumes from a vehicle or
a leak from a faulty gas appliance.
Exposure to CO at the workplace can occur in blast-furnace operations in the steel industry and when
gasoline or propane-powered forklifts, chainsaws, or other machines are used in confined spaces, such
as buildings, tunnels and mines.
Environmental exposure to CO can occur while traveling in motor vehicles (9-35 ppm); visiting urban
locations with heavily travelled roads (up to 50 ppm); or cooking and heating with domestic gas, kerosene,
coal, or wood (up to 30 ppm); as well as in fires and by environmental tobacco smoke.
Endogenous CO formation during normal metabolism leads to a background carboxyhemoglobin (COHb)
concentration of about 0.5-0.8%. Smokers are exposed to considerable high CO concentrations leading
to a COHb of about 3-8%. CO can remain in the bloodstream for up to 24 to 48 hours, depending on
factors such as physical activity. The half-life of COHb is approximately five hours.

1.3 What effect does CO have on the body?

CO is absorbed into the blood through the lungs. CO deprives the body of oxygen by binding very strongly
with red blood cells. The body responds by creating more red blood cells, which in turn thickens the blood
and puts a person at increased risk of clotting, heart attack, stroke, vascular disease and deep vein
thrombosis.

1.4 Why use a CO monitoring device with patients / clients?

When utilised as part of an overall quit smoking intervention, measuring a person’s CO levels can be an
effective tool to engage, motivate and chart the progress of smokers (Bittoun, 2008).
The more a person smokes, and the more intensely they inhale or ‘drag’ on their cigarette, the higher their
CO reading will be. CO monitoring therefore assists to determine the level of nicotine dependence and
provides the smoker with visible and real-time proof of the effects of smoking on their body. This can help
to motivate the person during a quit attempt by charting changes in CO levels over a period of time.

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2. Equipment and resources
2.1 What equipment is required to use the Smokerlyzer® device?

D-piece™ Disposable plastic tube* CO indication chart

(new or old style) (SteriBreath™)

Wipes – must be alcohol free. Written resource (optional / recommended) -

Non-sterile gloves - if a risk of contact with to provide to the consumer with CO monitoring
blood, body fluid or respiratory droplets. results (available on QHEPS via the Addiction
Services Info Hub under ‘Smokerlyzer’ tab.
Soap and water (preferred) or hand
sanitiser - Note: it is very important to allow
sanitiser to dry completely as alcohol can
damage the device sensor.

*The single-patient use disposable plastic tube (SteriBreath™) is required if the D-piece™ is being used
for multiple tests. The SteriBreath™ is optional if planning to dispose of the D-piece™ after one use.
Another less common option (not pictured) is the single-use OneBreath™ mouthpiece which
incorporates the filter of a D-piece™ and the length of a SteriBreath™.

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3. Device operation
Important note: Use of the Smokerlyzer® is considered an aerosol generating procedure. See infection
control section below to guide clinical practice and precautions.

3.1 Multiperson use Smokerlyzer® models

(Micro+™, piCO™ & piCObaby™)

The following videos can be viewed by staff to learn how to operate the device:

• How to use a Smokerlyzer® device - Dovetail Qld with Metro South Addiction Services.
• How to use a Smokerlyzer® device - Darling Downs HHS.
• How to: piCO™ Smokerlyzer® - Bedfont (manufacturer).

Step-by-step instructions (in addition, follow infection control as per section 4).
To ensure an accurate reading, conduct the test at least 10 minutes after the person’s last cigarette.
Step 1: Turn on the device (button on top) and insert the D-piece™ and
the disposable plastic tube SteriBreath™ (optional).

Step 2: Explain to the person: ‘Shortly I’ll ask you to take a deep breath
in and hold for 10-15 seconds. When the three beep count down is
complete, blow out into this clean mouthpiece, aiming to gradually
empty your lungs’.
Step 3: Tap the screen to activate the countdown and then ask the
person to take their deep breath in and hold it. After the three beep
countdown, indicate for the person to blow into the mouthpiece. *
Step 4: Once the result appears on the screen, refer to the indicator
chart to determine if the person falls into the green, orange or red zone. Take note of the different
indicators for adults, adolescents and unborn babies. Record the level and discuss with the person.
Step 5: Remove the D-piece™ between tests. Allow the sensor to purge with fresh air between tests.

Other considerations:
• Use a non-judgmental, non-threatening and culturally appropriate communication style when
performing the test and interpreting the CO monitoring results.
• If the person cannot hold their breath for the full 15 seconds, they can commence exhalation at a
comfortable point prior to the three beep count down.
• When holding the device, do not block the vent hole at the back with your hand.
• If the CO reading is lower than expected, this could be due to recent physical exercise, a faulty
device or the person may not be inhaling the smoke deeply.
• If the CO reading is higher than expected, this could be caused by the person inhaling deeply or
indicate a discrepancy in self-reported smoking, environmental factors (pollution/occupational
exposure), passive smoking or a fault with the Smokerlyzer® device.
• A very high or low reading may also indicate the device requiring calibration.

For more information: Refer to the manual available from the manufacturer’s website

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3.2 Single person use Smokerlyzer® model
(iCO™)

The iCO™ Smokerlyzer® is intended for use by a single person and may have cost implications to the
person or clinical service:

1. Person to download the Smokerlyzer® app on

their smart phone.
2. Ensure that the volume is turned up to
maximum.
3. Attach the device to the phone via the
headphone/charging port or via bluetooth and
turn on app.
4. Answer set up questions including PIN and
include the clinician’s email address.
5. Provide instructions on how to perform the test
(according to manufacturer’s instructions).

For more information: refer to the manual available from the manufacturer’s website.

3.3 Interpreting the CO monitoring results

The device will show the result in two formats:

• Parts per million (PPM)

• Percentage of CO in the blood (%COHb or %FCOHb).

PPM The number of CO molecules in a million parts of air.

%COHb The percentage of red blood cells carrying CO instead of oxygen

(percentage of carboxyhemoglobin).

%FCOHb Only available in piCObaby™ Smokerlyzer® model: The amount of CO in an unborn

baby’s blood (percentage of fetal carboxyhemoglobin).

Explaining the reading to a person (examples)

“The test shows that nearly 4% of your red blood cells are carrying
carbon monoxide instead of oxygen. This result puts you in the
‘red’ zone and indicates that you are a heavy smoker”.
Or
“The test shows that nearly 4% of the vital oxygen in your blood
stream has been replaced with carbon monoxide indicating that
you are a heavy smoker”.

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4. Infection control
4.1 How do I clean the device?

Never use alcohol wipes or organic solvents as this will damage the internal CO sensor. Use only the
cleaning wipes provided by the company with the device or use detergent wipes.

4.2 What infection control practices are required in routine care?

Prior to the face to face appointment, follow any COVID screening guidelines in place by your service
such as verbal screening or completing the Queensland Government COVID-19 Screening Assessment
on or before arrival.
When undertaking CO monitoring in routine, the following precautions must be taken to reduce the risk
of cross infection:
• Perform the test in accordance with the manufacturer’s instructions.
• Remember, D-piece™ can be multiple use OR single use; and SteriBreath™ is strictly single use.
Clinician judgement is required whether they choose to use the D-piece™ for single use or
multiple use due to cost implications. Also see COVID precautions section.
• Always use either a new D-piece™ for each person OR a new SteriBreath™ and the common D-
piece™ that is being used for multiple persons while maintaining infection control practices.
• Multiple use D-piece™ should be disposed of after maximum 30 days of use.
• Prior to use, hand hygiene must be performed by both the clinician and client (soap and water
preferred or <73.5% alcohol hand sanitiser – completely dried) – clinician and client. Alcohol
must not come in contact with the Smokerlyzer® as this can damage the sensor.
• Non-sterile gloves may be worn by the clinician if there is a risk of contact with blood or body fluid
/ respiratory droplets.
• Do not face the person, stand side-on. Continue to maintain physical distance where possible.
• At the completion of the assessment, ask the patient to remove the single use SteriBreath™
and/or D-piece™ and dispose one or both directly into the general waste.
• Clinician may decide to store patient specific D-pieces™ into a zip lock bag labelled with patient
name for 30 days during a pandemic situation.
• The clinician must clean the device after each use with a non-alcohol detergent cleaning wipe.
Do not use cleaning solutions / wipes that contain alcohol or other organic solutions.
• After cleaning with detergent wipes - leave the device to air dry for a minimum of 60 seconds.
• Hand hygiene must be performed following use of the device by both the clinician and the client.
• The device must be stored away from direct patient contact when not in use.

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4.3 How often do I need to change the mouthpieces?

The manufacturer (Bedfont) states the following:

• Bedfont recommends one D-piece™ can be used for multiple patients for a continuous 30 days in
conjunction with the single-patient-use SteriBreath™ mouthpieces.
• The disposable tubes (SteriBreath™) are single-use and must be disposed of after every use.
• A clinician can opt to use the OneBreath™ mouthpiece or D-piece™ for single use. This option is
recommended by Niche Medical, the Australian supplier of Smokerlyzer® products.
• Some smaller clinics or groups may choose to keep separate D-pieces™ for individual patients
(e.g. in a labelled zip lock bag) and then dispose of after 30 days.

4.4 Why is the D-piece™ re-useable?

• The manufacturer states that the D-piece™ incorporates a one-way valve and an infection control
filter. It states that the filter removes/traps 99% of airborne bacteria, 97% of viruses and any
moisture from the patient’s breath.
• The D-piece™ and OneBreath™ mouthpieces have been tested to filter viruses as small as 24
nanometers in diameter. The COVID-19 virus particle has a diameter of approximately 125
nanometers.
Note: CO testing should only be performed using a mouthpiece that utilises an inline filter to remove or
trap bacteria. Always check with the CO monitor manufacturer if the plastic mouthpieces provided
include a bacterial and viral control filter before use. The Smokerlyzer® brand is the only CO monitoring
device available in Australia at the time of writing these guidelines and utilises appropriate filters.

4.5 COVID Precautions

CO monitoring is considered an aerosol generating procedure; hence precautions are required to

prevent COVID transmission. When undertaking CO monitoring, follow local PPE recommendations for
aerosol generating procedures which may change based on current transmission risk level. For
example, this may include P2/N95 respirator or face mask, protective eyewear, gloves and gown/apron.
The below table is an example of a moderate risk escalation stance as detailed in the Pandemic
Response Guidance – Personal protective equipment in Healthcare delivery. Clinician judgement is
required for selection of correct PPE. These requirements also apply to outreach and in-home services.

Aerosol Generating Procedures

PPE guidance example for healthcare workers during moderate risk escalation

• P2/N95 respirator
Suspected / probable / confirmed COVID-19
• Protective eyewear
Important note: Avoid CO monitoring where
• Gown
possible in this situation
• Gloves

• Surgical mask
Non-COVID-19 patients
• Protective eyewear

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Suspension of CO monitoring may be required during high-risk transmission periods e.g. a local cluster
or community spread. Consult [email protected] for more information.
The Smokerlyzer® manufacturer (Bedfont) has a statement including a step by step guide/demonstration
video supporting the use of the device during COVID-19.

5. Associated equipment costs

5.1 Initial purchase and ongoing operation costs

Item Cost*

Smokerlyzer® device $693 - $1232 (depending on which device you choose to

purchase). The price includes 1 x box of 250 disposable
Steribreath™ mouthpieces, 1 x box of 12 D-pieces™ and
one packet of cleaning wipes.

A box of 250 Steribreath™

mouthpieces (disposable plastic $88 (approximately $0.35 per Steribreath™ mouthpiece).
tubes)

A box of 12 D-pieces™ $52.80 (approximately $4.40 per D-piece™)

iCO™ Smokerlyzer®. $132

(Single person multiuse: attaches
to a smart device/phone)

5.2 Calibration cost and frequency

Device calibration to maintain device accuracy is required every 6 months for older device models and
every 5 years for newer models.

Item Cost*

Calibration performed by Niche Medical - $66.

Calibration: Alternatively, a calibration kit can be purchased at a cost of
$622.60.

*Prices include GST and exclude delivery fees and are current at the time of writing - March 2021. These prices have been
provided by the Australian supplier for Smokerlyzer® devices (Niche Medical). There may be other brands and suppliers
available in Australia that staff members can research. This is a guide only, to confirm prices please contact the supplier for a
quote as the prices may change and discounts may be available for bulk purchases.

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5.3 How much would CO monitoring mouthpieces cost for a month?

1. Scenario 1: If a D-piece™ is used for multiple patients: If 10 breath tests were conducted per
month, the cost for mouthpieces (1 x D-piece™ plus 10 x SteriBreath™) would be approximately
$7.90 per month.
2. Scenario 2: If a clinician decides to use the D-piece™ for single use: If 10 breath tests were
conducted per month, the cost of mouth pieces would be approximately $40.40 (without
SteriBreath™) to $48.30 (with SteriBreath™) per month.

6. More information
• Visit the Bedfont website www.bedfont.com/ or Niche Medical website
www.nichemedical.com.au/
• Qld Health staff can visit the ‘Addiction Services Info Hub’ on QHEPS
• Contact the Metro South Addiction Services Preventative Team
P: 07 3299 3963 or E: [email protected]
• Email: [email protected]

7. Further reading
• Carbon monoxide meter: The essential clinical tool - the ‘stethoscope’ - of smoking cessation.
Bittoun, R. (2008). Journal of Smoking Cessation, 3(2), 69–70. DOI 10.1375/jsc.3.2.69
• COVID-19 does not stop good practice in smoking cessation: Safe use of CO analyzer for
smokers in the Covid era. Munarini et al (2021). Pulmonology Journal
• Guidance for carbon monoxide testing during COVID-19, 2020 – Darling Downs HHS factsheet
• The use of face masks and respirators in the context of Covid-19 – Infection Control Expert
Group – Australian Government 2021
• Video: How to use a Smokerlyzer® device - Dovetail Qld with Metro South Addiction Services
• Video: How to use a Smokerlyzer® device - Darling Downs HHS
• Bedfont (manufacturer) resources:
o Video: How to: piCO™ Smokerlyzer®
o Smokerlyzer® Range User Manual
o Infection Control and maintenance guidelines
o Coronavirus and Bedfont products update

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8. Version Control and Review History
Version Reviewed by Endorsement

V-2.0 September 2017 Natalie Davis (Author) - Health Promotion Officer, Metro South Smoking
New Document Addiction Services Preventative Team, MSAMHS Cessation Working Group
- Metro South Health. Metro South Addiction
Deepali Gupta (Author) - Advanced Pharmacist - Services Preventative
Metro South Health. Team
V-3.0 March 2021 Added Natalie Davis- Health Promotion Officer, Addiction Endorsed by Statewide
Section on Infection Services Preventative Team, MSAMHS - Metro Respiratory Network
Control - and COVID South Health. Steering committee March
precautions Deepali Gupta- Advanced Pharmacist - Metro 2021.
1. Added references and South Health.
further reading Jenny M Minchell - Dual Diagnosis Co-ordinator,
2. Added single patient Darling Downs Health.
use Smokerlyzer® Margaret McElrea - Respiratory Scientist,
model Queensland Children’s Hospital.
Isabel Chan- Senior Pharmacist, MSAMHS -
Metro South Health.

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