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Work with your doctor to order Trio-Smart by downloading the patient-doctor discussion guide.  

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Patient-Doctor Discussion Guide

Trio-Smart is a doctor-ordered breath test. The patient-doctor discussion guide includes an overview of Trio-Smart to help you have a conversation with your doctor about the test. It also includes a requisition form (test order form) that your doctor can complete and fax to 818-301-3222 or email to A Trio-Smart sample collection kit will then be shipped to you. 

The maximum patient responsibility for Trio-Smart is $349. Your insurance provider will first be billed, and you will be responsible for the balance, if applicable. Trio-Smart is covered at least in part by many common insurance plans, including Medicare and Medicaid. If you're interested in asking your insurance provider about coverage, you can reference CPT code: 91065 (billed twice) and NPI number: 1376006932. 

Work with your provider


Trio-Smart is the only breath test available that can measure all three of the primary fermented gases in your microbiome: hydrogen, methane, and hydrogen sulfide.

Measuring the three primary fermented gases can offer you and your doctor valuable and more complete insight into your GI symptoms, leading to a personalized treatment plan more quickly.

How does the Trio-Smart breath test work? 

Trio-Smart is a doctor-ordered breath test that uses an at-home sample collection kit. Using the kit, you collect your samples by breathing into 9 collection bags over a 2-hour period. The first bag is considered a “baseline” sample, and the remaining samples are collected after you drink a sugar substrate drink.


You then send your samples to our CLIA-certified lab (Prepaid shipping materials are included.), and the test results are reported to your doctor within a week.

A step-by-step sample collection instructional video is available here.


What does the Trio-Smart breath test measure? 

The Trio-Smart breath test measures the three primary fermented gases in your microbiome by way of your breath before and after a sugar substrate drink is consumed. The gases measured are hydrogen, methane, and hydrogen sulfide. 


Hydrogen is produced when certain bacteria consume sugars.

  • Hydrogen levels are considered abnormal when they rise greater than ≥20 ppm (parts per million) from the baseline within 90 minutes. 


Methane is produced when archaea (single-celled organisms similar to bacteria) consume hydrogen.

  • Methane levels are considered abnormal if they reach ≥10 ppm (parts per million) at any point during the breath test.


Hydrogen sulfide is produced when sulfate-reducing organisms consume hydrogen.

  • Hydrogen sulfide levels are considered abnormal if they reach ≥3ppm (parts per million) at any point during the breath test.


Elevated levels of hydrogen are indicative of SIBO.

SIBO, or small intestinal bacterial overgrowth, is defined as the presence of excessive numbers of bacteria in the small bowel, causing gastrointestinal symptoms.  The normal small bowel has lower levels of microbial colonization than does the colon. This normal balance is significantly disrupted with SIBO.  


SIBO can be a complex result of various medications and conditions, such as IBS, Celiac, Crohn’s disease, bowel surgeries, and several other gastrointestinal complications. The symptoms of SIBO can arise from the malabsorption of nutrients, alteration in intestinal permeability, inflammation, and/or immune activation that arises from the abnormal bacterial fermentation within the small bowel.

Elevated levels of methane are indicative of IMO.

IMO, or intestinal methanogenic overgrowth, is an overgrowth of methane-producing archaea in the small and large intestines. Methanogens are not bacteria (the “B” in SIBO) but are archaea and may also overgrow in the colon and not just the small intestine (the “SI'' in SIBO).  In humans, excess methane production appears to be caused by Methanobrevibacter smithii, which is the predominant methanogen in the human gut.

Elevated methane levels predict constipation, and the level of methane is correlated with the degree of constipation.

Elevated levels of hydrogen sulfide are indicative of excess hydrogen sulfide.

Excess hydrogen sulfide is a condition in which sulfate-reducing organisms produce high amounts of hydrogen sulfide in the gut. Excess hydrogen sulfide was undetectable by traditional breath testing prior to Trio-Smart, and patients with excess hydrogen sulfide may have appeared "normal" on previous breath tests. 


Elevated hydrogen sulfide levels predict more severe diarrhea, and the level of hydrogen sulfide is correlated with the degree of diarrhea. 


The three primary fermented gases in the microbiome - hydrogen, methane, and hydrogen sulfide - are not independent of each other.

In fact, these gases interact with each other in a complex way. Hydrogen is produced by fermenting bacteria but is also consumed by other organisms, resulting in the production of other gases, including methane and hydrogen sulfide. 


There is a balance-counterbalance effect between methane and hydrogen sulfide, illustrating a biochemical interdependency between microbes in the microbiome. These findings are important, because they suggest limitations when measuring only one or two gases. Only by measuring all three primary fermented gases can you get a more complete picture of your gut health. 

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  1. Pimentel, M., Saad, R., Long, M., et al. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American Journal of Gastroenterology, 2020.

  2. Rezaie, A., Buresi M., Lembo A., et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. American Journal of Gastroenterology, 2017. 

  3. Pimentel, M., Mathur, R. and Chang, C. Gas and the Microbiome. Current Gastroenterology, 2013. 

  4. Singer-Englar, T., Rezaie, A., Gupta, K., et al. Competitive Hydrogen Gas Utilization by Methane- and Hydrogen Sulfide-Producing Microorganisms and Associated Symptoms: Results of a Novel 4-Gas Breath Test Machine, AGA Abstracts, 2021.

  5. Pimentel, M., Hosseini, A., Chang, C., et al. Exhaled Hydrogen Sulfide Is Increased in Patients With Diarrhea: Results of a Novel Collection and Breath Testing Device, AGA Abstracts, 2021.

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