Israel Develops New ‘Sniff Test’ that can Predict if a Comatose Patient Will Regain Consciousness

So David took away the spear and the water jar at Shaul‘s head, and they left. No one saw or knew or woke up; all remained asleep; a deep sleep from Hashem had fallen upon them. (1 Samuel 26:12)

The nose knows! The olfactory system that centers on the sense of smell is the most ancient part of the brain, and its functioning provides an accurate measure of overall brain integrity. So perhaps it can provide information on the state of the brain itself.

If an unconscious person responds to smell through a slight change in his or her nasal airflow pattern, the patient is likely to regain consciousness, according to a new study conducted by scientists at the Weizmann Institute of Science in Rehovot and colleagues at the Loewenstein Rehabilitation Hospital in nearby Ra’anana.

According to the findings, just published in the prestigious journal Nature, 100% of the unconscious brain-injured patients who responded to a “sniff test” developed by the researchers regained consciousness during the four-year study period. The scientists think that this simple, inexpensive test can aid doctors in accurately diagnosing and determining treatment plans according to the patients’ degree of brain injury.

The scientists conclude in their article that this finding once again highlights the primal role of the sense of smell in human brain organization. After a severe brain injury, it is often hard to determine whether the person is conscious or unconscious, and current diagnostic tests can lead to an incorrect diagnosis in up to two-fifths of all cases.

“Misdiagnosis can be critical, as it can influence the decision of whether to disconnect patients from life support machines,” noted Dr. Anat Arzi, who led the research. “In regard to treatment, if it is judged that a patient is unconscious and doesn’t feel anything, physicians may not prescribe them painkillers that they might need.”

Arzi launched this research during her doctoral studies in the group of Prof. Noam Sobel of Weizmann neurobiology department and continued it as part of her postdoctoral research at the psychology department at the University of Cambridge in England.
Sobel’s lab studies olfaction in human subjects and in machines (electronic noses), and the team’s main goals are to study the systems-level neurobiological mechanisms of olfactory processing and ways in which chemical sensing affects human health and behavior.

The “consciousness test” developed by the researchers – in collaboration with Dr. Yaron Sacher, head of the department of traumatic brain injury rehabilitation at the rehabilitation hospital – is based on the principle that our nasal airflow changes in response to odor; for example, an unpleasant odor will lead to shorter and shallower sniffs. In healthy humans, the sniff-response can occur unconsciously in both wakefulness and sleep.

The study included 43 brain-injured patients at Loewenstein Hospital; the researchers briefly placed jars containing various odors under the patients’ noses, including a pleasant scent of shampoo, an unpleasant smell of rotten fish or no odor at all. At the same time, the scientists precisely measured the volume of air inhaled through the nose in response to the odors. Each jar was presented to the patient ten times in random order during the testing session, and each patient participated in several such sessions.

“Astonishingly, all patients who were classified as being in a ‘vegetative state’ yet responded to the sniff test, later regained consciousness, even if only minimal. In some cases, the result of the sniff test was the first sign that these patients were about to recover consciousness – and this reaction was observed days, weeks and even months prior to any other signs,” added Arzi. Moreover, the sniff response predicted not only who would regain consciousness, but also forecast with about 92% accuracy who would survive for at least three years.

“The fact that the sniff test is simple and potentially inexpensive makes it advantageous,” continued Arzi. “It can be performed at the patients’ bedside without the need to move them – and without complicated machinery.”

After a severe head injury, patients may fall into a comatose state – their eyes are closed and they do not have sleep-wake cycles. A coma usually lasts for about two weeks, after which there may either be a rapid improvement and return to consciousness, deterioration leading to death – or it could lead to a condition defined as a “disorder of consciousness.”

When spontaneous eye opening occurs but there is no evidence that the patients are aware of themselves or their surroundings, they are then diagnosed as being in a “vegetative state.” Alternatively, if a patient displays consistent signs of awareness, even if they are minimal and unstable, the patient will be classified as being in a “minimally conscious state.”

The gold standard diagnostic tool for assessing the level of consciousness is the Coma Recovery Scale (Revised), which examines responses to various stimuli: eye movements while tracking an object; turning the head toward a sound; and response to pain, among others. Since the rate of diagnosis errors may reach up to 40%, it is recommended to repeat the test at least five times.

But misdiagnosis may also occur when that test is conducted repeatedly. “In a well-known study, a patient diagnosed as being in a ‘vegetative state’ following a car accident was scanned in an MRI machine. While in the scanner, the researchers asked the patient to imagine that she was playing tennis and observed that her brain activity was similar to the brain activity of healthy people when they also imaged playing a tennis game. Suddenly, they realized: ‘Hold on a minute, she’s there. She hears us and is responding to our requests. She simply has no way of communicating,’ ” said Arzi. “There are also known cases of people who were diagnosed in a ‘vegetative state’ but when they regained consciousness, they were able to recount in detail what was occurring while supposedly vegetative. Diagnosing the level of consciousness of a patient who has suffered a severe head injury is a major clinical challenge. The sniff test we have developed may provide a simple tool to tackle this challenge,” Arzi concluded.