Repeatability of the measurement of exhaled volatile metabolites using selected ion flow tube mass spectrometry

Determination of the two-compartment model parameters of exhaled HCN by fast negative photoionization mass spectrometry

Breath exhaled hydrogen cyanide (HCN) has been identified to be associated with several respiratory diseases. Accurately distinguishing the concentration and release rate of different HCN sources is of great value in clinical research. However, there are still significant challenges due to the high adsorption and low concentration characteristics of exhaled HCN. In this study, a two-compartment kinetic model method based on negative photoionization mass spectrometry was developed to simultaneously determine the kinetic parameters including concentrations and release rates in the airways and alveoli. The influences of the sampling line diameter, length, and temperature on the response time of the sampling system were studied and optimized, achieving a response time of 0.2 s. The negative influence of oral cavity-released HCN was reduced by employing a strategy based on anatomical lung volume calculation. The calibration for HCN in the dynamic range of 0.5-100 ppbv and limit of detection (LOD) at 0.3 ppbv were achieved. Subsequently, the experiments of smoking, short-term passive smoking, and intake of bitter almonds were performed to examine the influences of endogenous and exogenous factors on the dynamic parameters of the model method. The results indicate that compared with steady-state concentration measurements, the kinetic parameters obtained using this model method can accurately and significantly reflect the changes in different HCN sources, highlighting its potential for HCN-related disease research.

Identification of Corrosive Volatile Compounds Found in the Headspace of Chicken Noodle Soup Retorted in Metal Cans

This study investigated the development of volatile compounds in the headspace of canned chicken noodle soup (and sought to develop appropriate testing methods). The primary objective of this study was to identify compounds in the soup that were responsible for the initiation of the corrosion in the cans. The long-term goal of these studies is to develop an efficient method to investigate how headspace volatile compounds in foods could cause corrosion defects in metal cans and how these could be corrected without undermining the quality and safety of the food. To determine and to evaluate the volatile compounds in the canned soups, selected ion flow tube-mass spectrometry (SIFT-MS) was used. The coatings of the tested cans were carefully stripped off and analyzed using this SIFT-MS method. High levels of sulfur-containing volatile compounds and organic acids were detected in both the soups and the coatings. It was concluded that during the retorting of the sealed cans filled with chicken soup, sulfur-containing volatile compounds formed and entered the headspace of the tested cans and interacted with the coating, leading to the formation of blackened stains.

Real-Time Non-Invasive Monitoring of Short-Chain Fatty Acids in Exhaled Breath

Short-chain fatty acids (SCFAs) are important metabolites produced by the gut microbiome as a result of the fermentation of non-digestible polysaccharides. The most abundant SCFAs are acetic acid, propionic acid, and butyric acid which make up 95% of this group of metabolites in the gut. Whilst conventional analysis SCFAs is done using either blood or fecal samples, SCFAs can also be detected in exhaled breath using proton transfer reaction-time-of-flight- mass spectrometry (PTR-ToF-MS) using H₃O⁺ for ionization. However, no investigation has been performed to characterize the reactions of SCFAs with H₃O⁺ and with other reagent ions, such as O₂ ⁺ and NO⁺. Gas-phase samples of acetic acid, propionic acid, and butyric acid were analyzed with SRI/PTR-ToF-MS under dry and humid conditions. The ions generated and their distribution was determined for each reagent ion. It was found the humidity did not influence the product ion distribution for each SCFA. Using H₃O⁺ as a reagent ion, SRI/PTR-ToF-MS analysis of an exhaled breath sample was performed in real-time to demonstrate the methodology. The presence of SCFAs in exhaled breath was confirmed by thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS). Breath sampling repeatability was within acceptable limits (<15%) for an analytical methodology for each investigated SCFA. Nutritional intervention studies could potentially benefit from real-time monitoring of exhaled SCFAs as an alternative to measuring SCFAs invasively in blood or fecal samples since it is non-invasive, and requires minimal time investment from participants.

Selected ion flow tube mass spectrometry for targeted analysis of volatile organic compounds in human breath

The analysis of volatile organic compounds (VOCs) within breath for noninvasive disease detection and monitoring is an emergent research field that has the potential to reshape current clinical practice. However, adoption of breath testing has been limited by a lack of standardization. This protocol provides a comprehensive workflow for online and offline breath analysis using selected ion flow tube mass spectrometry (SIFT-MS). Following the suggested protocol, 50 human breath samples can be analyzed and interpreted in <3 h. Key advantages of SIFT-MS are exploited, including the acquisition of real-time results and direct compound quantification without need for calibration curves. The protocol includes details of methods developed for targeted analysis of disease-specific VOCs, specifically short-chain fatty acids, aldehydes, phenols, alcohols and alkanes. A procedure to make custom breath collection bags is also described. This standardized protocol for VOC analysis using SIFT-MS is intended to provide a basis for wider application and the use of breath analysis in clinical studies.

Exhaled Breath Reflects Prolonged Exercise and Statin Use during a Field Campaign

Volatile organic compounds (VOCs) in exhaled breath provide insights into various metabolic processes and can be used to monitor physiological response to exercise and medication. We integrated and validated in situ a sampling and analysis protocol using proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS) for exhaled breath research. The approach was demonstrated on a participant cohort comprising users of the cholesterol-lowering drug statins and non-statin users during a field campaign of three days of prolonged and repeated exercise, with no restrictions on food or drink consumption. The effect of prolonged exercise was reflected in the exhaled breath of participants, and relevant VOCs were identified. Most of the VOCs, such as acetone, showed an increase in concentration after the first day of walking and subsequent decrease towards baseline levels prior to walking on the second day. A cluster of short-chain fatty acids including acetic acid, butanoic acid, and propionic acid were identified in exhaled breath as potential indicators of gut microbiota activity relating to exercise and drug use. We have provided novel information regarding the use of breathomics for non-invasive monitoring of changes in human metabolism and especially for the gut microbiome activity in relation to exercise and the use of medication, such as statins.

Exhaled breath analysis in disease detection

Investigating the use of exhaled breath analysis to diagnose and monitor different diseases has attracted much interest in recent years. This review introduces conventionally used methods and some emerging technologies aimed at breath analysis and their relevance to lung disease, airway inflammation, gastrointestinal disorders, metabolic disorders and kidney diseases. One section correlates breath components and specific diseases, whereas the other discusses some unique ideas, strategies, and devices to analyze exhaled breath for the diagnosis of some common diseases. This review aims to briefly introduce the potential application of exhaled breath analysis for the diagnosis and screening of various diseases, thereby providing a new avenue for the detection of non-invasive diseases.

Noninvasive monitoring of fibre fermentation in healthy volunteers by analyzing breath volatile metabolites: lessons from the FiberTAG intervention study

The fermentation of dietary fibre (DF) leads to the production of bioactive metabolites, the most volatile ones being excreted in the breath. The aim of this study was to analyze the profile of exhaled breath volatile metabolites (BVM) and gastrointestinal symptoms in healthy volunteers after a single ingestion of maltodextrin (placebo) versus chitin-glucan (CG), an insoluble DF previously shown to be fermented into short-chain fatty acids (SCFA) by the human microbiota in vitro. Maltodextrin (4.5 g at day 0) or CG (4.5 g at day 2) were added to a standardized breakfast in fasting healthy volunteers (n = 15). BVM were measured using selected ion flow tube mass spectrometry (SIFT-MS) throughout the day. A single ingestion of 4.5 g CG did not induce significant gastrointestinal discomfort. Untargeted metabolomics analysis of breath highlighted that 13 MS-fragments (among 408 obtained from ionizations of breath) discriminated CG versus maltodextrin acute intake in the posprandial state. The targeted analysis revealed that CG increased exhaled butyrate and 5 other BVM - including the microbial metabolites 2,3-butanedione and 3-hydroxybutanone - with a peak observed 6 h after CG intake. Correlation analyses with fecal microbiota (Illumina 16S rRNA sequencing) spotlighted Mitsuokella as a potential genus responsible for the presence of butyric acid, triethylamine and 3-hydroxybutanone in the breath. In conclusion, measuring BMV in the breath reveals the microbial signature of the fermentation of DF after a single ingestion. This protocol allows to analyze the time-course of released bioactive metabolites that could be proposed as new biomarkers of DF fermentation, potentially linked to their biological properties. Trial registration: Clinical Trials NCT03494491. Registered 11 April 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03494491.

Highly selective and sensitive online measurement of trace exhaled HCN by acetone-assisted negative photoionization time-of-flight mass spectrometry with in-source CID

Exhaled hydrogen cyanide (HCN) has been extensively investigated as a promising biomarker of the presence of Pseudomonas aeruginosa in the airways of patients with cystic fibrosis (CF) disease. Its concentration profile for exhalation can provide useful information for medical disease diagnosis and therapeutic procedures. However, the complexity of breath gas, like high humidity, carbon dioxide (CO₂) and trace organic compounds, usually leads to quantitative error, poor selectivity and sensitivity for HCN with some of existing analytical techniques. In this work, acetone-assisted negative photoionization (AANP) based on a vacuum ultraviolet (VUV) lamp with a time-of- flight mass spectrometer (AANP-TOFMS) was firstly proposed for online measurement of trace HCN in human breath. In-source collision-induced dissociation (CID) was adopted for sensitivity improvement and the signal response of the characteristic ion CN^- (m/z 26) was improved by about 24-fold. For accurate and reliable analysis of the exhaled HCN, matrix influences in the human breath including humidity and CO₂ were investigated, respectively. A Nafion tube was used for online dehumidification of breath samples. Matrix-adapted calibration in the concentration range of 0.5-50 ppbv with satisfactory dynamic linearity and repeatability was obtained. The limit of quantitation (LOQ) for HCN at 0.5 ppbv was achieved in the presence of 100% relative humidity and 4% CO₂. Finally, the method was successfully applied for online determination of human mouth- and nose-exhaled HCN, and the nose-exhaled HCN were proved to be reliable for assessing systemic HCN levels for individuals. The results are encouraging and highlight the potential of AANP-TOFMS with in-source CID as a selective, accurate, sensitive and noninvasive technique for determination of the exhaled HCN for CF clinical diagnosis and HCN poisoning assessment.

Breath Volatile Organic Compound Profiling of Colorectal Cancer Using Selected Ion Flow-tube Mass Spectrometry

OBJECTIVE

BACKGROUND:: Breath VOCs have the potential to noninvasively diagnose cancer.

METHODS

Exhaled breath samples were collected using 2-L double-layered Nalophan bags, and were analyzed using selected-ion-flow-tube mass-spectrometry. Gold-standard test for comparison was endoscopy for luminal inspection and computed tomography (CT) to confirm cancer recurrence. Three studies were conducted: RESULTS:: CONCLUSION:: This study suggests the association of a single breath biomarker with the primary presence and recurrence of CRCa. Further multicenter validation studies are required to validate these findings.

Assessment of a Noninvasive Exhaled Breath Test for the Diagnosis of Oesophagogastric Cancer

Question

What is the diagnostic accuracy of a breath test for esophagogastric cancer?

Findings

In a multicenter diagnostic study of 335 patients, including 172 patients with esophagogastric cancer, the breath test demonstrated good diagnostic accuracy.

Meaning

This study suggests the potential of breath analysis as a noninvasive tool in the diagnosis of esophagogastric cancer.

Importance

Early esophagogastric cancer (OGC) stage presents with nonspecific symptoms.

Objective

The aim of this study was to determine the accuracy of a breath test for the diagnosis of OGC in a multicenter validation study.

Design, Setting, and Participants

Patient recruitment for this diagnostic validation study was conducted at 3 London hospital sites, with breath samples returned to a central laboratory for selected ion flow tube mass spectrometry (SIFT-MS) analysis. Based on a 1:1 cancer:control ratio, and maintaining a sensitivity and specificity of 80%, the sample size required was 325 patients. All patients with cancer were on a curative treatment pathway, and patients were recruited consecutively. Among the 335 patients included; 172 were in the control group and 163 had OGC.

Interventions

Breath samples were collected using secure 500-mL steel breath bags and analyzed by SIFT-MS. Quality assurance measures included sampling room air, training all researchers in breath sampling, regular instrument calibration, and unambiguous volatile organic compounds (VOCs) identification by gas chromatography mass spectrometry.

Main Outcomes and Measures

The risk of cancer was identified based on a previously generated 5-VOCs model and compared with histopathology-proven diagnosis.

Results

Patients in the OGC group were older (median [IQR] age 68 [60-75] vs 55 [41-69] years) and had a greater proportion of men (134 [82.2%]) vs women (81 [47.4%]) compared with the control group. Of the 163 patients with OGC, 123 (69%) had tumor stage T3/4, and 106 (65%) had nodal metastasis on clinical staging. The predictive probabilities generated by this 5-VOCs diagnostic model were used to generate a receiver operator characteristic curve, with good diagnostic accuracy, area under the curve of 0.85. This translated to a sensitivity of 80% and specificity of 81% for the diagnosis of OGC.

Conclusions and Relevance

This study shows the potential of breath analysis in noninvasive diagnosis of OGC in the clinical setting. The next step is to establish the diagnostic accuracy of the test among the intended population in primary care where the test will be applied.

Standardization procedures for real-time breath analysis by secondary electrospray ionization high-resolution mass spectrometry

Despite the attractiveness of breath analysis as a non-invasive means to retrieve relevant metabolic information, its introduction into routine clinical practice remains a challenge. Among all the different analytical techniques available to interrogate exhaled breath, secondary electrospray ionization high-resolution mass spectrometry (SESI-HRMS) offers a number of advantages (e.g., real-time, yet wide, metabolome coverage) that makes it ideal for untargeted and targeted studies. However, so far, SESI-HRMS has relied mostly on lab-built prototypes, making it difficult to standardize breath sampling and subsequent analysis, hence preventing further developments such as multi-center clinical studies. To address this issue, we present here a number of new developments. In particular, we have characterized a new SESI interface featuring real-time readout of critical exhalation parameters such as CO₂, exhalation flow rate, and exhaled volume. Four healthy subjects provided breath specimens over a period of 1 month to characterize the stability of the SESI-HRMS system. A first assessment of the repeatability of the system using a gas standard revealed a coefficient of variation (CV) of 2.9%. Three classes of aldehydes, namely 4-hydroxy-2-alkenals, 2-alkenals and 4-hydroxy-2,6-alkedienals―hypothesized to be markers of oxidative stress―were chosen as representative metabolites of interest to evaluate the repeatability and reproducibility of this breath analysis analytical platform. Median and interquartile ranges (IQRs) of CVs for CO₂, exhalation flow rate, and exhaled volume were 3.2% (1.5%), 3.1% (1.9%), and 5.0% (4.6%), respectively. Despite the high repeatability observed for these parameters, we observed a systematic decay in the signal during repeated measurements for the shorter fatty aldehydes, which eventually reached a steady state after three/four repeated exhalations. In contrast, longer fatty aldehydes showed a steady behavior, independent of the number of repeated exhalation maneuvers. We hypothesize that this highly molecule-specific and individual-independent behavior may be explained by the fact that shorter aldehydes (with higher estimated blood-to-air partition coefficients; approaching 100) mainly get exchanged in the airways of the respiratory system, whereas the longer aldehydes (with smaller estimated blood-to-air partition coefficients; approaching 10) are thought to exchange mostly in the alveoli. Exclusion of the first three exhalations from the analysis led to a median CV (IQR) of 6.7 % (5.5 %) for the said classes of aldehydes. We found that such intra-subject variability is in general much lower than inter-subject variability (median relative differences between subjects 48.2%), suggesting that the system is suitable to capture such differences. No batch effect due to sampling date was observed, overall suggesting that the intra-subject variability measured for these series of aldehydes was biological rather than technical. High correlations found among the series of aldehydes support this notion. Finally, recommendations for breath sampling and analysis for SESI-HRMS users are provided with the aim of harmonizing procedures and improving future inter-laboratory comparisons.

Direct analysis of volatile organic compounds in foods by headspace extraction atmospheric pressure chemical ionisation mass spectrometry

RATIONALE

The rapid screening of volatile organic compounds (VOCs) by direct analysis has potential applications in the areas of food and flavour science. Currently, the technique of choice for VOC analysis is gas chromatography/mass spectrometry (GC/MS). However, the long chromatographic run times and elaborate sample preparation associated with this technique have led a movement towards direct analysis techniques, such as selected ion flow tube mass spectrometry (SIFT-MS), proton transfer reaction mass spectrometry (PTR-MS) and electronic noses. The work presented here describes the design and construction of a Venturi jet-pump-based modification for a compact mass spectrometer which enables the direct introduction of volatiles for qualitative and quantitative analysis.

METHODS

Volatile organic compounds were extracted from the headspace of heated vials into the atmospheric pressure chemical ionization source of a quadrupole mass spectrometer using a Venturi pump. Samples were analysed directly with no prior sample preparation. Principal component analysis (PCA) was used to differentiate between different classes of samples.

RESULTS

The interface is shown to be able to routinely detect problem analytes such as fatty acids and biogenic amines without the requirement of a derivatisation step, and is shown to be able to discriminate between four different varieties of cheese with good intra and inter-day reproducibility using an unsupervised PCA model. Quantitative analysis is demonstrated using indole standards with limits of detection and quantification of 0.395 μg/mL and 1.316 μg/mL, respectively.

CONCLUSIONS

The described methodology can routinely detect highly reactive analytes such as volatile fatty acids and diamines without the need for a derivatisation step or lengthy chromatographic separations. The capability of the system was demonstrated by discriminating between different varieties of cheese and monitoring the spoilage of meats.

Pentane and other volatile organic compounds, including carboxylic acids, in the exhaled breath of patients with Crohn's disease and ulcerative colitis

A study has been carried out on the volatile organic compounds (VOCs) in the exhaled breath of patients suffering from inflammatory bowel disease (IBD), comprising 136 with Crohn's disease (CD) and 51 with ulcerative colitis (UC), together with a cohort of 14 healthy persons as controls. Breath samples were collected by requesting the patients to inflate Nalophan bags, which were then quantitatively analysed using selected ion flow tube mass spectrometry (SIFT-MS). Initially, the focus was on n-pentane that had previously been quantified in single exhalations on-line to SIFT-MS for smaller cohorts of IBD patients. It was seen that the median concentration of pentane was elevated in the bag breath samples of the IBD patients compared to those of the healthy controls, in accordance with the previous study. However, the absolute median pentane concentrations in the bag samples were about a factor of two lower than those in the directly analysed single exhalations-a good illustration of the dilution of VOCs in the samples of breath collected into bags. Accounting for this dilution effect, the concentrations of the common breath VOCs, ethanol, propanol, acetone and isoprene, were largely as expected for healthy controls. The concentrations of the much less frequently measured hydrogen sulphide, acetic acid, propanoic acid and butanoic acid were seen to be more widely spread in the exhaled breath of the IBD patients compared to those for the healthy controls. The relative concentrations of pentane and these other VOCs weakly correlate with simple clinical activity indices. It is speculated that, potentially, hydrogen sulphide and these carboxylic acids could be exhaled breath biomarkers of intestinal bacterial overgrowth, which could assist therapeutic intervention and thus alleviate the symptoms of IBD.

Bacterial volatiles and diagnosis of respiratory infections

Breath testing has enormous potential in the medical diagnostic field. The underlying complexity and perceived availability of adequate specimens, combined with a lack of knowledge of the metabolic pathways that give rise to compounds that are sources of analytes detectable in breath, has greatly slowed development. These real obstacles have recently been largely overcome in the use of breath testing to identify patients with cystic fibrosis associated Pseudomonas aeruginosa infection and tuberculosis. This review summarizes progress made in the characterization of microbial volatiles produced by major lower respiratory tract bacterial pathogens, and their potential use as diagnostic markers in patient breath testing.

SIFT-MS and FA-MS methods for ambient gas phase analysis: developments and applications in the UK

The origins of SIFT created to study interstellar chemistry and SIFT-MS developed for ambient gas and exhaled breath analysis and the UK centres in which these techniques are being exploited.

Analysis of human breath samples using a modified thermal desorption: gas chromatography electrospray ionization interface

A two-stage thermal desorption/secondary electrospray ionization/time-of-flight mass spectrometry for faster targeted breath profiling has been studied. A new secondary electrospray ionization (SESI) source was devised to constrain the thermal desorption plume and promote efficient mixing in the ionization region. Further, a chromatographic pre-separation stage was introduced to suppress interferences from siloxanes associated with thermal desorption profiles of exhaled breath samples.In vitro tests with 5-nonanone indicated an increased sensitivity and a lowered limit-of-detection, both by a factor of ~4, the latter to an on-trap mass of 14.3 ng, equivalent to a sampled breath concentration of 967 pptv. Analysis of the mass spectrometric responses from 20 breath samples acquired sequentially from a single participant indicated enhanced reproducibility (reduced relative standard deviations (RSD) for 5-nonanone, benzaldehyde and 2-butanone were 28 %, 16% and 14% respectively. The corresponding values for an open SESI source were that 5-nonanone was not detected, with %RSD of 39% for benzaldehyde and 31% for 2-butanone).The constrained source with chromatographic pre-separation resulted in an increase in the number of detectable volatile organic compounds (VOCs) from 260 mass spectral peaks with an open SESI source to 541 peaks with the constrained source with pre-separation. Most of the observed VOCs were present at trace levels, at less than 2.5% of the intensity of the base peak.Seventeen 2.5 dm(3) distal breath samples were collected from asthma patients and healthy controls respectively, and subjected to comparative high-throughput screening using thermal desorption/SESI/time-of-flight mass spectrometry (TD-SESI-ToFMS). Breath metabolites were detected by using a background siloxane ion (hexamethylcyclotrisiloxane m/z 223.0642) as an internal lockmass. Eleven breath metabolites were selected from the breath research literature and successfully targeted. These data reinforce the proposition that TD-SESI-MS has potential for development as a rapid screening method for disease stratification and targeted metabolism profiling.

Real-time monitoring of exhaled drugs by mass spectrometry

Future individualized patient treatment will need tools to monitor the dose and effects of administrated drugs. Mass spectrometry may become the method of choice to monitor drugs in real time by analyzing exhaled breath. This review describes the monitoring of exhaled drugs in real time by mass spectrometry. The biological background as well as the relevant physical properties of exhaled drugs are delineated. The feasibility of detecting and monitoring exhaled drugs is discussed in several examples. The mass spectrometric tools that are currently available to analyze breath in real time are reviewed. The technical needs and state of the art for on-site measurements by mass spectrometry are also discussed in detail. Off-line methods, which give support and are an important source of information for real-time measurements, are also discussed. Finally, some examples of drugs that have already been successfully detected in exhaled breath, including propofol, fentanyl, methadone, nicotine, and valproic acid are presented. Real-time monitoring of exhaled drugs by mass spectrometry is a relatively new field, which is still in the early stages of development. New technologies promise substantial benefit for future patient monitoring and treatment.

Effects of dietary nutrients on volatile breath metabolites

Breath analysis is becoming increasingly established as a means of assessing metabolic, biochemical and physiological function in health and disease. The methods available for these analyses exploit a variety of complex physicochemical principles, but are becoming more easily utilised in the clinical setting. Whilst some of the factors accounting for the biological variation in breath metabolite concentrations have been clarified, there has been relatively little work on the dietary factors that may influence them. In applying breath analysis to the clinical setting, it will be important to consider how these factors may affect the interpretation of endogenous breath composition. Diet may have complex effects on the generation of breath compounds. These effects may either be due to a direct impact on metabolism, or because they alter the gastrointestinal flora. Bacteria are a major source of compounds in breath, and their generation of H₂, hydrogen cyanide, aldehydes and alkanes may be an indicator of the health of their host.

Breath isoprene concentrations in persons undergoing general anesthesia and in healthy volunteers

Human breath contains an abundance of volatile organic compounds (VOCs). Analysis of breath VOC may be used for diagnosis of various diseases or for on-line monitoring in anesthesia and intensive care. However, VOC concentrations largely depend on the breath sampling method and have a large inter-individual variability. For the development of breath tests, the influence of breath sampling methods and study subject characteristics on VOC concentrations has to be known. Therefore, we investigated the VOC isoprene in 62 study subjects during anesthesia and 16 spontaneously breathing healthy volunteers to determine (a) the influence of artificial and spontaneous ventilation and (b) the influence of study subject characteristics on breath isoprene concentrations. We used ion molecule reaction mass spectrometry for high-resolution breath-by-breath analysis of isoprene. We found that persons during anesthesia had significantly increased inspiratory and end-expiratory isoprene breath concentrations. Measured isoprene concentrations (median [first quartile-third quartile]) were in the anesthesia group: 54 [40-79] ppb (inspiratory) and 224 [171-309] ppb (end-expiratory), volunteer group: 14 [11-17] ppb (inspiratory) and 174 [124-202] ppb (end-expiratory). Higher end-tidal CO(2) concentrations in ventilated subjects were associated with higher expiratory isoprene levels. Furthermore, inspiratory and end-expiratory isoprene concentrations were correlated during anesthesia (r = 0.603, p < 0.001). Multivariate analysis showed that men had significantly higher end-expiratory isoprene concentrations than women. Rebreathing of isoprene from the anesthesia machine possibly accounts for the observed increase in isoprene in the anesthesia group.

Reproducibility and respiratory function correlates of exhaled breath fingerprint in chronic obstructive pulmonary disease

BACKGROUND

The electronic nose (e nose) provides distinctive breath fingerprints for selected respiratory diseases. Both reproducibility and respiratory function correlates of breath fingerprint are poorly known.

OBJECTIVES

To measure reproducibility of breath fingerprints and to assess their correlates among respiratory function indexes in elderly healthy and COPD subjects.

METHOD

25 subjects (5 COPD patients for each GOLD stage and 5 healthy controls) over 65 years underwent e-nose study through a seven sensor system and respiratory function tests at times 0, 7, and 15 days. Reproducibility of the e nose pattern was computed. The correlation between volatile organic compound (VOC) pattern and respiratory function/clinical parameters was assessed by the Spearman's rho.

MEASUREMENTS AND MAIN RESULTS

VOC patterns were highly reproducible within healthy and GOLD 4 COPD subjects, less among GOLD 1-3 patients.VOC patterns significantly correlated with expiratory flows (Spearman's rho ranging from 0.36 for MEF25% and sensor Co-Buti-TPP, to 0.81 for FEV1% and sensor Cu-Buti-TPP p<0.001)), but not with residual volume and total lung capacity.

CONCLUSIONS

VOC patterns strictly correlated with expiratory flows. Thus, e nose might conveniently be used to assess COPD severity and, likely, to study phenotypic variability. However, the suboptimal reproducibility within GOLD 1-3 patients should stimulate further research to identify more reproducible breath print patterns.

Measurement of breath acetone concentrations by selected ion flow tube mass spectrometry in type 2 diabetes

Selected ion flow tube-mass spectrometry (SIFT-MS) can measure volatile compounds in breath on-line in real time and has the potential to provide accurate breath tests for a number of inflammatory, infectious and metabolic diseases, including diabetes. Breath concentrations of acetone in type 2 diabetic subjects undertaking a long-term dietary modification programme were studied. Acetone concentrations in the breath of 38 subjects with type 2 diabetes were determined by SIFT-MS. Anthropomorphic measurements, dietary intake and medication use were recorded. Blood was analysed for beta hydroxybutyrate (a ketone body), HbA1c (glycated haemoglobin) and glucose using point-of-care capillary (fingerprick) testing. All subjects were able to undertake breath manoeuvres suitable for analysis. Breath acetone varied between 160 and 862 ppb (median 337 ppb) and was significantly higher in men (median 480 ppb versus 296 ppb, p = 0.01). In this cross-sectional study, no association was observed between breath acetone and either dietary macronutrients or point-of-care capillary blood tests. Breath analysis by SIFT-MS offers a rapid, reproducible and easily performed measurement of acetone concentration in ambulatory patients with type 2 diabetes. The high inter-individual variability in breath acetone concentration may limit its usefulness in cross-sectional studies. Breath acetone may nevertheless be useful for monitoring metabolic changes in longitudinal metabolic studies, in a variety of clinical and research settings.

Volatile compounds in health and disease

PURPOSE OF REVIEW

To summarize the recent progress made in noninvasive monitoring of volatile compounds in exhaled breath and above biological liquids, as they are becoming increasingly important in assessing the nutritional and clinical status and beginning to provide support to conventional clinical diagnostics and therapy. To indicate the potential of these developments in medicine and the specific areas which are currently under investigation.

RECENT FINDINGS

The significance of the following breath gases and their concentrations are reported: acetone and the influence of diet; ammonia confirmed as an indicator of dialysis efficacy; hydrogen and the (13)CO(2)/(12)CO(2) ratio (following the ingestion of (13)C-labeled compounds) as related to gastric emptying and bowel transit times; hydrogen cyanide released by Pseudomonas and its detection in breath of children with cystic fibrosis; and multiple trace compounds in breath of patients with specific pathophysiological conditions and 'metabolic profiling'.

SUMMARY

Advanced analytical methods, especially exploiting mass spectrometry, are moving breath analysis towards the clinical setting; some trace gas metabolites are already being exploited in diagnosis and therapy. Much effort is being given to the search for biomarkers of tumours in the body. HCN as an indicator of the presence of Pseudomonas in the airways has real potential in therapeutically alleviating the symptoms of cystic fibrosis.

Background levels and diurnal variations of hydrogen cyanide in breath and emitted from skin

The hydrogen cyanide (HCN) concentration in exhaled human breath and skin gas samples collected with different sampling techniques was measured using near-infrared cavity ring-down spectroscopy. The median baseline HCN concentrations in samples provided by 19 healthy volunteers 2-4 h after the last meal depended on the employed sampling technique: 6.5 parts per billion by volume (ppbv) in mixed (dead space and end-tidal) mouth-exhaled breath collected to a gas sampling bag, 3.9 ppbv in end-tidal mouth-exhaled breath, 1.3 ppbv in end-tidal nose-exhaled breath, 1.0 ppbv in unwashed skin and 0.6 ppbv in washed skin samples. Diurnal measurements showed that elevated HCN levels are to be expected in mouth-exhaled breath samples after food and drink intake, which suggests HCN generation in the oral cavity. The HCN concentrations in end-tidal nose-exhaled breath and skin gas samples were correlated, and it is concluded that these concentrations best reflect systemic HCN levels.

Can volatile compounds in exhaled breath be used to monitor control in diabetes mellitus?

Although it has been known for centuries that there are compounds in exhaled breath that are altered in disease, it is only in the last few decades that it has been possible to measure them with sufficient accuracy and precision to make them clinically useful. The clinical utility of breath analysis has also been limited by the practical difficulties of collecting representative breath samples, free from contaminants. More recent methods of breath analysis have allowed real-time analysis of breath, eliminating the need for sample collection, and therefore potentially allowing the rapid feedback of results to patient and clinician. One possible future application of breath analysis may be the monitoring of metabolic control in patients with diabetes mellitus. This perspective article provides an overview of the studies of breath analysis in diabetes, focusing on the breath metabolites; acetone, isoprene and also methyl nitrate that have previously been reported to be altered in diabetes, highlighting the factors that may potentially confound their interpretation. Specific attention is given to selected ion flow tube mass spectrometry (SIFT-MS) and proton transfer reaction mass spectrometry (PTR-MS), because they are techniques that have been developed specifically for the absolute quantification of breath metabolites in real time, although reference is made to some of the alternative techniques, including sensors and optical devices. Whilst breath analysis, using SIFT-MS, PTR-MS and other sensitive techniques, can potentially be used for the non-invasive monitoring of metabolic conditions that may include diabetes mellitus, further work is required in terms of the clinical and analytical validation. Furthermore, it is unclear at present what breath metabolites should be monitored and what factors may confound their interpretation. Although a non-invasive method of monitoring glycaemic control is clearly desirable, it will be important to demonstrate its analytical comparability with the well-established and validated methods for blood glucose measurement.

Progress in SIFT-MS: breath analysis and other applications

The development of selected ion flow tube mass spectrometry, SIFT-MS, is described from its inception as the modified very large SIFT instruments used to demonstrate the feasibility of SIFT-MS as an analytical technique, towards the smaller but bulky transportable instruments and finally to the current smallest Profile 3 instruments that have been located in various places, including hospitals and schools to obtain on-line breath analyses. The essential physics and engineering principles are discussed, which must be appreciated to design and construct a SIFT-MS instrument. The versatility and sensitivity of the Profile 3 instrument is illustrated by typical mass spectra obtained using the three precursor ions H(3)O(+), NO(+) and O(2)(+)·, and the need to account for differential ionic diffusion and mass discrimination in the analytical algorithms is emphasized to obtain accurate trace gas analyses. The performance of the Profile 3 instrument is illustrated by the results of several pilot studies, including (i) on-line real time quantification of several breath metabolites for cohorts of healthy adults and children, which have provided representative concentration/population distributions, and the comparative analyses of breath exhaled via the mouth and nose that identify systemic and orally-generated compounds, (ii) the enhancement of breath metabolites by drug ingestion, (iii) the identification of HCN as a marker of Pseudomonas colonization of the airways and (iv) emission of volatile compounds from urine, especially ketone bodies, and from skin. Some very recent developments are discussed, including the quantification of carbon dioxide in breath and the combination of SIFT-MS with GC and ATD, and their significance. Finally, prospects for future SIFT-MS developments are alluded to.

Breath ammonia and trimethylamine allow real-time monitoring of haemodialysis efficacy

Non-invasive monitoring of breath ammonia and trimethylamine using Selected-ion-flow-tube mass spectroscopy (SIFT-MS) could provide a real-time alternative to current invasive techniques. Breath ammonia and trimethylamine were monitored by SIFT-MS before, during and after haemodialysis in 20 patients. In 15 patients (41 sessions), breath was collected hourly into Tedlar bags and analysed immediately (group A). During multiple dialyses over 8 days, five patients breathed directly into the SIFT-MS analyser every 30 min (group B). Pre- and post-dialysis direct breath concentrations were compared with urea reduction, Kt/V and creatinine concentrations. Dialysis decreased breath ammonia, but a transient increase occurred mid treatment in some patients. Trimethylamine decreased more rapidly than reported previously. Pre-dialysis breath ammonia correlated with pre-dialysis urea in group B (r(2) = 0.71) and with change in urea (group A, r(2) = 0.24; group B, r(2) = 0.74). In group B, ammonia correlated with change in creatinine (r(2) = 0.35), weight (r(2) = 0.52) and Kt/V (r(2) = 0.30). The ammonia reduction ratio correlated with the urea reduction ratio (URR) (r(2) = 0.42) and Kt/V (r(2) = 0.38). Pre-dialysis trimethylamine correlated with Kt/V (r(2) = 0.21), and the trimethylamine reduction ratio with URR (r(2) = 0.49) and Kt/V (r(2) = 0.36). Real-time breath analysis revealed previously unmeasurable differences in clearance kinetics of ammonia and trimethylamine. Breath ammonia is potentially useful in assessment of dialysis efficacy.