Biomarker validation—room air variation during human breath investigations

The engineering of ion mobility spectrometers has made significant advances in recent years with new levels of sensitivity being achieved which facilitate their use, for example, in the medical analysis of trace components in human breath. In the study reported here direct measurements of 10 mL of exhaled air were carried out using ion mobility spectrometry (IMS) and the influence of the ambient air composition on the validation of potential biomarkers carefully considered. Changes in the IMS-signals observed within a room used for clinical studies were analysed in the absence of clinical staff. A time series of one measurement every hour of ambient air was referenced against clean bottled synthetic air for comparison using two different IMS instruments equipped with multi-capillary columns (MCC). 26 different peaks were identified and selected for the signal intensity monitoring during 1 week. Some peaks show no changes, while certain peaks varied with time in a seemlingly random manner. Correlated peak intensity changes were observed as well as changes apparently relating to variations of the ventilation system during day and night cycling. It is important to fully understand these variation if incorrect conclusions are to be avoided during, for example, the important hunt for validatable biomarkers. These results will be applicable not only to IMS studies but to all experimental design strategies in this fields regardless of the selected instrumentation. As an example it is possible to cite a particular time series where a particular peak observed within the IMS-Chromatogram shows an analyte intensity decrease within the room air between the evening and the next morning of 75%. On a subsequent day the increase between the morning and the evening was observed by a factor of about 3. During 4 days, setting the mean value to 100%, an increase of up to 173% and the decrease of up to 21% were observed. In case of measurements near to the detection limit of the method of investigation, the influence of the surrounding inhaled air must be considered carefully. The daily changes of the concentrations of specific analytes in the ambient air should be taken into account in addition to the measurement of the analyte concentrations taken from the exhaled air of a patient. Recommendations will be made covering more robust validation strategies which include near-simultaneous background ambient air measurements alongside synthetic air measurements in clinical studies. Care should be taken to avoid unnecessary changes to the ambient room air during measurements such as caused by doors opening during the entire measurement time. Ambient air measurements should be included with sampling on the patient and the surrounding air, before and after measurement of the patient breath.     

Signals of neutropenia in human breath?

Children undergoing systemic chemotherapy often suffer from severe immunosuppression usually associated to severe neutropenia (neutrophils <?0.5 x 10⁹/l). Clinical courses during those periods range from asymptomatic to septic general conditions. Development of septic symptoms can be very fast and life-threatening. Swift detection of risk factors in those patients is therefore needed. So far no early, rapid and reliable marker or tool exists. Ion-Mobility-Spectrometry coupled with a Multi-Capillary-Column (IMS-MCC) can analyze more than 600 volatile components from exhaled air within a few minutes and hence is a potential, rapid detection-tool. As a proof of concept we measured the exhaled breath of 11 patients with neutropenia and 10 healthy controls ranging from 3 to 18 years of age at the time of measurement. Ten milliliters breath samples were taken at the outpatient clinic and analyzed with an onsite IMS-MCC (BreathDiscovery, B&S Analytik, Dortmund, Germany). Dead-space-volume was adapted to two groups (small 250 ml, large 500 ml). Interestingly 59 differing peaks were measured. Eleven were significantly different (p?≤?0.05), three of which highly significant (p?≤?0.01) in Mann-Whitney-Rank-Sum-testing. The corresponding analytes used in the decision tree are 2-Propanol, D-Limonene and Acetone. The analytes with the lowest rank sum identified are 2-Hexanone, Iso-Propylamine and 1-Butanol. Eventually we were able to show a three-step-decision-tree, which discerns the 21 samples except one from each group. Sensitivity was 90 % and specificity was 91 %. Naturally these findings need further confirmation within a bigger population. Our pilot-study proves that Ion-Mobility-Spectrometry coupled with a Multi-Capillary-Column is a feasible rapid diagnostic tool in the setting of a pediatric oncology out-patient clinic for patients 3 years and older. Our first results furthermore encourage additional analysis as to whether patients at risk for septic events during immunosuppression can be diagnosed in advance by rapidly assessing risk factors such as Neutropenia in exhaled breath.     

Determination of fentanyl in human breath by solid-phase microextraction and gas chromatography–mass spectrometry

Fentanyl, a kind of intravenous narcotic analgesic, is widely used in clinical anesthesia. As a potential pollution, it was detected in both the air of the cardiothoracic operating room and patients' expiratory circuit. However, whether the fentanyl in patients' expiratory circuit is exhaled by patients is unknown. In this study, breath samples were taken from the expiratory circuits of anesthetic machine linked to the patients who received intravenous fentanyl, a solid-phase microextraction (SPME) coupled with gas chromatography–mass spectrometry (GC–MS) method was developed to detect and quantify fentanyl in breath samples. The parameters influencing adsorption (extraction time, temperature,) and desorption (desorption time) of the analyte on the fiber were investigated and validated for method development. The developed method was proved to be simple, easy, and inexpensive and offer high sensitivity and reproducibility. Linear range was obtained from 0.05 ng/mL to 0.8 ng/mL. The limit of detection was 0.01 ng/mL while an interday precision of less than 12.13% (n = 5) could be achieved. Six patients were involved in this study; results showed presence of fentanyl in the breath of patients who received intravenous fentanyl, and fentanyl concentrations in breath varied from 6.00 to 20.89 pg/mL. In conclusion, fentanyl can be exhaled by patients who received intravenous fentanyl.     

Selected ion flow tube mass spectrometry of exhaled breath condensate headspace

Collection of exhaled breath condensate (EBC) is a relatively simple noninvasive method of breath analysis; however, no data have been reported that would relate concentration of volatile compounds in EBC to their gaseous concentrations in exhaled air. The aim of the study was to investigate which volatile compounds are present in EBC and how their concentrations relate to results of direct breath analysis. Thus, samples of EBC were collected in a standard way from several subjects and absolute levels of several common volatile breath metabolites (ammonia, acetone, ethanol, methanol, propanol, isoprene, hydrogen cyanide, formaldehyde and acetaldehyde) were then determined in their headspace using selected ion flow tube mass spectrometry (SIFT-MS). Results are compared with those from on-line breath analyses carried out immediately before collecting the EBC samples. It has been demonstrated that SIFT-MS can be used to quantify the concentrations of volatiles in EBC samples and that, for methanol, ammonia, ethanol and acetone, the EBC concentrations correlate with the direct breath levels. However, the EBC concentrations of isoprene, formaldehyde, acetaldehyde, hydrogen cyanide and propanol do not correlate with direct breath measurements. Copyright (c) 2008 John Wiley & Sons, Ltd.     

Detection of human metabolites using multi-capillary columns coupled to ion mobility spectrometers

The human breath contains indicators of human health and delivers information about different metabolism processes of the body. The detection and attribution of these markers provide the possibility for new, non-invasive diagnostic methods. In the recent study, ion mobility spectrometers are used to detect different volatile organic metabolites in human breath directly. By coupling multi-capillary columns using ion mobility spectrometers detection limits down to the ng/L and pg/L range are achieved. The sampling procedure of human breath as well as the detection of different volatiles in human breath are described in detail. Reduced mobilities and detection limits for different analytes occurring in human breath are reported. In addition, spectra of exhaled air using ion mobility spectrometers obtained without any pre-concentration are presented and discussed in detail. Finally, the potential use of IMS with respect to lung infection diseases will be considered.     

Human breath analysis: methods for sample collection and reduction of localized background effects

Solid-phase microextraction (SPME) was applied, in conjunction with gas chromatography–mass spectrometry, to the analysis of volatile organic compounds (VOCs) in human breath samples without requiring exhaled breath condensate collection. A new procedure, exhaled breath vapor (EBV) collection, involving the active sampling and preconcentration of a breath sample with a SPME fiber fitted inside a modified commercial breath-collection device, the RTube™, is described. Immediately after sample collection, compounds are desorbed from the SPME fiber at 250 °C in the GC-MS injector. Experiments were performed using EBV collected at −80 °C and at room temperature, and the results compared to the traditional method of collecting exhaled breath condensate at −80 °C followed by passive SPME sampling of the collected condensate. Methods are compared in terms of portability, ease-of-use, speed of analysis, and detection limits. The need for a clean air supply for the study subjects is demonstrated using several localized sources of VOC contaminants including nail polish, lemonade, and gasoline. Various simple methods to supply clean inhaled air to a subject are presented. Chemical exposures are used to demonstrate the importance of providing cleaned air (organic vapor respirator) or an external air source (tubing stretched to a separate room). These techniques allow for facile data interpretation by minimizing background contaminants. It is demonstrated herein that this active SPME breath-sampling device provides advantages in the forms of faster sample collection and data analysis, apparatus portability and avoidance of power or cooling requirements, and performance for sample collection in a contaminated environment.      

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

Selected ion flow tube mass spectrometry, SIFT-MS, has been used to determine the repeatability of the analysis of volatile metabolites within the breath of healthy volunteers, with emphasis on the influence of sampling methodology. Baseline instrument specific coefficients of variability for examined metabolites were as follows: acetone (1%), ammonia (1%), isoprene (2%), propanol (6%), ethanol (7%), acetic acid (7%), and hydrogen cyanide (19%). Metabolite concentration and related product ion count rate were identified as strong determinants of measurement variation. With the exception of ammonia, an orally released metabolite, variability in repeated on-line breath analysis tended to be lower for metabolites of systemic origin. Standardization of sampling technique improved the repeatability of the analysis of selected metabolites. Off-line (bag) alveolar breath sampling, as opposed to mixed (whole) breath sampling, likewise improved the repeatability of the analysis of all metabolites investigated, with the exception of acetic acid. We conclude that SIFT-MS analysis of common volatile metabolites within the breath of healthy volunteers is both reliable and repeatable. For selected metabolites, the finding that repeatability is improved through modification of sampling methodology may have implications in terms of future recommended practices.     

New method for determination of trihalomethanes in exhaled breath: Applications to swimming pool and bath environments

A method for the estimation of the human intake of trihalomethanes (THMs), namely chloroform, bromodichloromethane, dibromochloromethane and bromoform, during showering and bathing is reported. The method is based on the determination of these compounds in exhaled breath that is collected by solid adsorption on Tenax using a device specifically designed for this purpose. Instrumental measurements were performed by automatic thermal desorption coupled to gas chromatography with electron capture detection. THMs in exhaled breath samples were determined during showering and swimming pool attendance. The levels of these compounds in indoor air and water were also determined as reference for interpretation of the exhaled breath results. The THM concentrations in exhaled breath of the volunteers measured before the exposure experiments showed a close correspondence with the THMs levels in indoor air where the sampler was located. Limits of detection in exhaled breath were dependent on THM analytes and experimental sites. They ranged between 170 and 710 ng m⁻³ in the swimming pool studies and between 97 and 460 ng m⁻³ in the showering studies. Application of this method to THMs determination during showering and swimming pool activities revealed statistically significant increases in THMs concentrations when comparing exhaled breath before and after exposure.     

Analysis of human breath with micro extraction techniques and continuous monitoring of carbon dioxide concentration

The detection of volatile organic compounds (VOCs) in human breath can be useful for the clinical routine diagnosis of several diseases in a non-invasive manner. Traditional methods of breath analysis have some major technical problems and limitations. Membrane extraction with a sorbent interface (MESI), however, has many advantages over current methods, including good selectivity and sensitivity, and is well suited for breath analysis. The aim of this project was to develop a simple and reproducible sampling device and method based on the MESI system for breath analysis. The feasibility and validity of the MESI system was tested with real human breath samples. Internal standard calibration methods were used for the quantitative analysis of various breath samples. Calibration curves for some main components (target analytes such as acetone and pentane) were determined in the research. The optimized stripping-side and feeding-side gas velocities were determined. The use of breath CO₂ as an internal standard for the analysis of breath VOCs is an effective method to solve the difficulties associated with variations in the target analyte concentrations in a sample, which are attributed to mass losses and different breathing patterns of different subjects. In this study, the concentration of breath acetone was successfully expressed normalized to CO₂ as in the alveolar air. Breath acetone of healthy males and females profiled at different times of the day was plotted using the MESI system, and results were consistent with the literature. This technique can be used for monitoring breath acetone concentrations of diabetic patients and for applications with other biomarker monitoring.     

Detection of ferricyanide as a probe for the effect of hematocrit in whole blood biosensors.

Measurement of the concentration of an analyte in whole blood can be influenced by a range of factors; the red cell content or hematocrit (Hct) of the sample, the distribution and rate of movement of analyte between red cells and plasma, the amount of protein in solution, the viscosity of the sample and fouling of the sensor. The effect of the red cells is the major factor that must be taken into account. Using the analyte molality rather than the analyte molarity, the theoretical response for a range of analytes which are found in plasma and in the red cells can be calculated. For an analyte which is found in plasma alone, the effect of hematocrit is significant, with a bias of -1% per %Hct; if the analyte can freely and rapidly diffuse between the red cells and plasma, this bias is reduced to zero. Using ferrocyanide as a model analyte, the effects of fouling and reduced sample viscosity were measured to be -0.2% per %Hct, giving an overall bias of -1.2% per %Hct, a level of bias which is not clinically acceptable. This bias can be negated by measuring the hematocrit separately and incorporating it into the measurement algorithm. Such a correction is essential for the correct measurement of the concentration of an analyte in whole blood.     

The effect of analyte concentration range on measurement errors obtained by NIR spectroscopy

Near infrared spectroscopy (NIRS) was employed to quantify five compounds, ammonium, glucose, glutamate, glutamine, and lactate, in conditions similar to those obtained in animal cell cultivations over varying ranges of analyte concentrations. These components represent the primary nutrients and wastes of animal cells for which such noninvasive monitoring schemes are required for development of accurate control schemes. Ideal cultivation conditions involve maintaining concentrations of these components as low as 1 mM each, however, it is not known if measurements of these compounds can be accurately accomplished at such a low level. We have found that NIRS measurements of these analytes over narrow and low (0-1 mM) concentration ranges yield measurement errors of roughly 11% of the concentration range. By contrast, wide concentration ranges (0-30 mM) yield measurement errors of roughly 1.6% of the concentration range. Decreasing the concentration range over which an analyte is quantified in four out of five cases decreases the optimal spectral range by 100 cm(-1) for measurement by partial least squares regression analysis. There appears a similarity in the ratio of (standard error of prediction (SEP)/concentration range) which may provide an estimation of the anticipated SEP to be obtained for measurement over a new concentration range. It was found that for the five analytes evaluated here, the ratio of SEP to concentration range divided by that obtained for a second concentration range is equal to a fairly constant value of 6.6. This relationship was found to be followed reasonably well by an extensive number of measurement results reported in the literature for similar conditions.     

人体呼出气中挥发性有机化合物的检测方法

呼出气检测作为一种潜在的新型临床检测手段受到广泛关注。本文详细综述了人体呼出气中挥发性有机化合物(VOCs)的各类检测方法和技术,分别对色谱法、质谱法和光谱及传感器法的原理、特点和最新研究进展进行了介绍,对照总结了目前已确定的异戊二烯、丙酮等疾病生物标志物的各种分析方法和实测数据,并展望了未来的研究动向。     

Treatment of turkeys with nitroimidazoles: Impact of the selection of target analytes and matrices on an effective residue control

In several animal studies turkeys were treated with different nitroimidazoles (Dimetridazole, Metronidazole, Ronidazole, Ipronidazole). After slaughtering, different matrices (breast muscle, leg muscle, liver, plasma, retina) were analysed for their analyte content, for the percentage of hydroxy-metabolites, for homogeneity, stability and bound, and conjugated residues. The tests showed that for animals treated with Dimetridazole and Ipronidazole, the hydroxy-metabolites (2-hydroxymethyl-1-methyl-5-nitroimidazole (HMMNI) and 1-methyl-2-(2′-hydroxyisopropyl)-5-nitroimidazole (IPZOH)) are the relevant target analytes, whereas for animals treated with Ronidazole and Metronidazole, the parent drug itself is the most relevant analyte. In muscle samples an inhomogeneous analyte distribution was found. Degradation studies showed a rapid decline of the analyte concentration in muscle and liver samples stored at room temperature and a decelerated degradation at 4 °C. In plasma and retina samples, however, the analytes were stable during storage under the same conditions. In these matrices the analytes were found to be present in considerably higher concentrations than in muscle or liver and could be detected for a longer period of time after withdrawal of the medication. Therefore, plasma or retina can be recommended as target matrices for the residue control of nitroimidazoles in turkeys.     

Breathing Rhythm Variations during Wash-In Do Not Influence Exhaled Volatile Organic Compound Profile Analyzed by an Electronic Nose

E-noses are innovative tools used for exhaled volatile organic compound (VOC) analysis, which have shown their potential in several diseases. Before obtaining a full validation of these instruments in clinical settings, a number of methodological issues still have to be established. We aimed to assess whether variations in breathing rhythm during wash-in with VOC-filtered air before exhaled air collection reflect changes in the exhaled VOC profile when analyzed by an e-nose (Cyranose 320). We enrolled 20 normal subjects and randomly collected their exhaled breath at three different breathing rhythms during wash-in: (a) normal rhythm (respiratory rate (RR) between 12 and 18/min), (b) fast rhythm (RR > 25/min) and (c) slow rhythm (RR < 10/min). Exhaled breath was collected by a previously validated method (Dragonieri et al., J. Bras. Pneumol. 2016) and analyzed by the e-nose. Using principal component analysis (PCA), no significant variations in the exhaled VOC profile were shown among the three breathing rhythms. Subsequent linear discriminant analysis (LDA) confirmed the above findings, with a cross-validated accuracy of 45% (p = ns). We concluded that the exhaled VOC profile, analyzed by an e-nose, is not influenced by variations in breathing rhythm during wash-in.     

Development of a method for metabolomic analysis of human exhaled breath condensate by gas chromatography–mass spectrometry in high resolution mode

Exhaled breath condensate (EBC) is a promising biofluid scarcely used in clinical analysis despite its non-invasive sampling. The main limitation in the analysis of EBC is the lack of standardized protocols to support validation studies. The aim of the present study was to develop an analytical method for analysis of human EBC by GC–TOF/MS in high resolution mode. Thus, sample preparation strategies as liquid–liquid extraction and solid-phase extraction were compared in terms of extraction coverage. Liquid–liquid extraction resulted to be the most suited sample preparation approach providing an average extraction efficiency of 77% for all compounds in a single extraction. Different normalization approaches were also compared to determine which strategy could be successfully used to obtain a normalized profile with the least variability among replicates of the same sample. Normalization to the total useful mass spectrometry signal (MSTUS) proved to be the most suited strategy for the analysis of EBC from healthy individuals (n = 50) reporting a within-day variability below 7% for the 51 identified compounds and a suited data distribution in terms of percentage of metabolites passing the Skewness and Kurtosis test for normality distribution. The composition of EBC was clearly dominated by the presence of fatty acids and derivatives such as methyl esters and amides, and volatile prenol lipids. Therefore, EBC offers the profile of both volatile and non-volatile components as compared to other similar biofluids such as exhaled breath vapor, which only provides the volatile profile. This human biofluid could be an alternative to others such as serum/plasma, urine or sputum to find potential markers with high value for subsequent development of screening models.     

Gas generation and preconcentration coupled to gas phase molecular absorption spectrometry: a powerful tool for the simultaneous determination of analytes forming volatile compounds

Different methods for a simultaneous determination of several analytes forming volatile compounds at room temperature are described. The main steps of these methods are: continuous generation, collection in a cryogenic trap, revolatilization, measurement of the volatile compounds by Gas Phase Molecular Absorption Spectrometry and resolution by multi-wavelength methods. Several mixtures containing 2, 3 or 4 components have been studied: 1) elements forming covalent hydrides; 2) arsenic organometallic compounds forming volatile gases with a similar structure to arsine; and 3) sulphur species that can evolve volatile compounds. Under the optimum conditions obtained for each mixture, detection limits range from 0.8 ng/mL (dimethylarsinic acid) to 2 microg/mL (SCN(-)).     

Pilot Study on Exhaled Breath Analysis for a Healthy Adult Population in Hawaii

Fast diagnostic results using breath analysis are an anticipated possibility for disease diagnosis or general health screenings. Tests that do not require sending specimens to medical laboratories possess capabilities to speed patient diagnosis and protect both patient and healthcare staff from unnecessary prolonged exposure. The objective of this work was to develop testing procedures on an initial healthy subject cohort in Hawaii to act as a range-finding pilot study for characterizing the baseline of exhaled breath prior to further research. Using comprehensive two-dimensional gas chromatography (GC×GC), this study analyzed exhaled breath from a healthy adult population in Hawaii to profile the range of different volatile organic compounds (VOCs) and survey Hawaii-specific differences. The most consistently reported compounds in the breath profile of individuals were acetic acid, dimethoxymethane, benzoic acid methyl ester, and n-hexane. In comparison to other breathprinting studies, the list of compounds discovered was representative of control cohorts. This must be considered when implementing proposed breath diagnostics in new locations with increased interpersonal variation due to diversity. Further studies on larger numbers of subjects over longer periods of time will provide additional foundational data on baseline breath VOC profiles of control populations for comparison to disease-positive cohorts.     

Statistical and bioinformatical methods to differentiate chronic obstructive pulmonary disease (COPD) including lung cancer from healthy control by breath analysis using ion mobility spectrometry

Human breath analysis is a powerful and especially a non-invasive technique for the monitoring and hopefully also for the diagnosis of respiratory diseases, including chronic obstructive pulmonary disease (COPD). The exhaled breath of 95 patients suffering COPD and of 35 healthy controls was investigated using an Ion Mobility Spectrometer (IMS) coupled to a Multi-Capillary Column (MCC) without any pre-separation or pre-enrichment. Starting with the results from a Mann–Whitney-Wilcoxon rank sum test to find analytes with the highest potential with respect to differentiation, box and whisker plots, metabolic maps and probability charts were introduced and compared. In addition, the sensitivity, specificity, positive and negative predictive values and the accuracy of the relation were also summarized. The findings were compared to the results of a principal component analysis. Finally, decision trees were introduced to visualize the interdependencies between the analytes and the classifications. The application of these biostatistical methods with simultaneous inclusion of several VOCs for disease classification by ion mobility spectrometry of human breath will provide much more information than using single peaks and single concentration dependencies for disease classification and discrimination of various groups. Towards the future application of potential biomarkers for clinical diagnostic procedures, complex analytical methods, such as ion mobility spectrometry, need statistical and bioinformatical tools which are simple in application, visualize the results and support decisions on the basis of the data obtained from measurements of analytes in exhaled human breath.     

A coaxially heated membrane introduction mass spectrometry interface for the rapid and sensitive on-line measurement of volatile and semi-volatile organic contaminants in air and water at parts-per-trillion levels

A coaxially heated membrane introduction mass spectrometry (MIMS) sampling interface is presented that demonstrates improved on-line performance for the direct measurement of semi-volatile organic compounds (SVOCs) in air and water samples at parts-per-trillion levels. The device is based on a polydimethylsiloxane (PDMS) capillary hollow fibre membrane (HFM) in a pneumatically assisted "flow-over" configuration that is resistively heated on the membrane interior via a coaxial nichrome wire, establishing a thermal gradient counter to the analyte concentration gradient. This arrangement allows for continuous and/or pulsed heating modes, affording excellent sensitivity for the on-line measurement of SVOCs while retaining sensitivity for volatile organic compounds (VOCs). In addition, the signal response time for SVOCs is reduced substantially over conventional "flow-over" MIMS interfaces. Separation and quantitation of analytes are achieved using quadrupole ion trap tandem mass spectrometry.     

Detection of volatile organic compounds indicative of human presence in the air

Volatile organic compounds were collected and analyzed from a variety of indoor and outdoor air samples to test whether human‐derived compounds can be readily detected in the air and if they can be associated with human occupancy or presence. Compounds were captured with thermal desorption tubes and then analyzed by gas chromatography with mass spectrometry. Isoprene, a major volatile organic compound in exhaled breath, was shown to be the best indicator of human presence. Acetone, another major breath‐borne compound, was higher in unoccupied or minimally occupied areas than in human‐occupied areas, indicating that its majority may be derived from exogenous sources. The association of endogenous skin‐derived compounds with human occupancy was not significant. In contrast, numerous compounds that are found in foods and consumer products were detected at elevated levels in the occupied areas. Our results revealed that isoprene and many exogenous volatile organic compounds consumed by humans are emitted at levels sufficient for detection in the air, which may be indicative of human presence.