Human exhaled air analytics: biomarkers of diseases

Over the last few years, breath analysis for the routine monitoring of metabolic disorders has attracted a considerable amount of scientific interest, especially since breath sampling is a non-invasive technique, totally painless and agreeable to patients. The investigation of human breath samples with various analytical methods has shown a correlation between the concentration patterns of volatile organic compounds (VOCs) and the occurrence of certain diseases. It has been demonstrated that modern analytical instruments allow the determination of many compounds found in human breath both in normal and anomalous concentrations. The composition of exhaled breath in patients with, for example, lung cancer, inflammatory lung disease, hepatic or renal dysfunction and diabetes contains valuable information. Furthermore, the detection and quantification of oxidative stress, and its monitoring during surgery based on composition of exhaled breath, have made considerable progress. This paper gives an overview of the analytical techniques used for sample collection, preconcentration and analysis of human breath composition. The diagnostic potential of different disease-marking substances in human breath for a selection of diseases and the clinical applications of breath analysis are discussed.     

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.      

Validity Assessment for the Results of Three Inflammatory Markers in Exhaled Breath Condensate: A Pilot Study

This study was initiated to assess the validity of eicosanoid determination in exhaled breath condensate by immunoassays. The results were compared to those obtained from liquid chromatographic methods with mass spectrometric detection and with the theoretical spiked amount of condensate. Therefore, spiked exhaled breath condensate was prepared achieving samples for comparison of identical aliquots. The three most often analysed inflammatory markers in the literature, i.e. leukotriene B₄, prostaglandin E₂, and 8-isoprostane-prostaglandin F_2α were selected for comparison. Three concentrations of spiked and non-spiked breath condensate matrix were examined. There was an up to 800% overestimation of the eicosanoid quantities revealed by the immunoassay kits used in this study compared to the liquid chromatographic method with mass spectrometric detection which was in line with the nominal amount spiked. Full validation of immunoassay for the determination of inflammatory markers should be performed before further interpretations and consequences will be taken from the absolute values quantified by enzyme-immunoassays. For improving the accuracy of enzyme linked immunoassay (ELISA) results a collaborative work applying ELISA and LC–MS–MS should be performed in order to spotlight the advantages of the ELISA-method.     

多批次肝衰竭患者呼出气体的电喷雾萃取电离质谱检测及代谢组学数据分析

采用高分辨电喷雾萃取电离质谱(EESI-MS)技术对肝衰竭患者和健康志愿者呼出气体样本进行快速检测, 结合多块偏最小二乘分析(MB-PLS)方法, 对多批次获取的呼出气体代谢数据进行统计建模分析, 并与传统的PLS方法进行比较. 结果表明, MB-PLS方法能有效消除批次差异对统计建模的影响. 此外, 利用MB-PLS模型变量VIP值对变量进行筛选, 可降低数据的冗余, 消除无关变量对模型的影响, 从而有效提高了模型的性能.     

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.     

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.     

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.     

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.     

Identification of volatile lung cancer markers by gas chromatography–mass spectrometry: comparison with discrimination by canines

In this work, a chromatographic method for identification of volatile organic compounds was compared with canine recognition. Gas chromatography and mass spectrometry (GC-TOF MS) were used for determination of concentrations of trace gases present in human breath. The technique enables rapid determination of compounds in human breath, at the parts per billion level. Linear correlations were from 0.83-234.05 ppb, the limit of detection was the range 0.31-0.75 ppb, and precision, expressed as relative standard deviation (RSD), was less than 10.00 %. Moreover, trained dogs are able to discriminate breath samples of patients with diagnosed cancer. We found a positive correlation between dog indications and the ethyl acetate and 2-pentanone content of breath (r = 0.85 and r = 0.97, respectively). The methods presented for detection of lung cancer markers in exhaled air could be used as a potential non-invasive tool for screening. In addition, the canine method is relatively simple and inexpensive in comparison with chromatography.     

Comprehensive Two-Dimensional Gas Chromatography–Mass Spectrometry Analysis of Exhaled Breath Compounds after Whole Grain Diets

Exhaled breath is a potential noninvasive matrix to give new information about metabolic effects of diets. In this pilot study, non-targeted analysis of exhaled breath volatile organic compounds (VOCs) was made by comprehensive two-dimensional gas chromatography–mass spectrometry (GCxGC-MS) to explore compounds relating to whole grain (WG) diets. Nine healthy subjects participated in the dietary intervention with parallel crossover design, consisting of two high-fiber diets containing whole grain rye bread (WGR) or whole grain wheat bread (WGW) and 1-week control diets with refined wheat bread (WW) before both diet periods. Large interindividual differences were detected in the VOC composition. About 260 VOCs were detected from exhaled breath samples, in which 40 of the compounds were present in more than half of the samples. Various derivatives of benzoic acid and phenolic compounds, as well as some furanones existed in exhaled breath samples only after the WG diets, making them interesting compounds to study further.     

Design-of-experiment optimization of exhaled breath condensate analysis using a miniature differential mobility spectrometer (DMS)

Analytical instruments that can measure small amounts of chemicals in complicated biological samples are often useful as diagnostic tools. However, it can be challenging to optimize these sensors using actual clinical samples, given the heterogeneous background and composition of the test materials. Here we use gas chromatography-differential mobility spectrometry (GC/DMS) to analyze the chemical content of human exhaled breath condensate (EBC). Ultimately, this system can be used for non-invasive disease diagnostics. Many parameters can be adjusted within this instrument system, and we implemented a factorial design-of-experiments to systematically test several combinations of parameter settings while concurrently analyzing effects and interactions.We examined four parameters that affect sensitivity and detection for our instrument, requiring a 2⁴ factorial design. We optimized sensor function using EBC samples spiked with acetone, a known clinical biomarker in breath. Two outputs were recorded for each experiment combination: number of chemicals detected, and the amplitude of acetone signal. Our goal is to find the best parameter combination that yields the highest acetone peak while also preserving the largest number of other chemical peaks in the spectra. By optimizing the system, we can conduct further clinical experiments with our sensor more efficiently and accurately.     

Diagnostics of calibration methods: model adequacy of UV‐based determinations

Models such as ordinary least squares, independent component analysis, principle component analysis, partial least squares, and artificial neural networks can be found in the calibration literature. Linear or nonlinear methods can be used to explain the structure of the same phenomenon. Each type of model has its own advantages with respect to the other. These methods are usually grouped taxonomically, but different models can sometimes be applied to the same data set. Taxonomically, ordinary least square and artificial neural network use completely different analytical procedures but are occasionally applied to the same data set. The aim of the study of methodological superiority is to compare the residuals of models because the model with the minimum error is preferred in real analyses. Calibration models, in general, are based on deterministic and stochastic parts; in other words, the data are equal to the model + the error. Explaining a model solely using statistics such as the coefficient of determination or its related significance values is sometimes inadequate. The errors of a model, also called its residuals, must have minimum variance compared to its alternatives. Additionally, the residuals must be unpredictable, uncorrelated, and symmetric. Under these conditions, the model can be considered adequate. In this study, calibration methods were applied to the raw materials, hydrochlorothiazide and amiloride hydrochloride, of a drug, as well as a sample of the drug tablet. The applied chemical procedure was fast, simple, and reproducible. The various linear and nonlinear calibration methods mentioned above were applied, and the adequacy of the calibration methods was compared according to their residuals.     

An exploratory comparative study of volatile compounds in exhaled breath and emitted by skin using selected ion flow tube mass spectrometry

Selected ion flow tube mass spectrometry (SIFT-MS) has been used to carry out a pilot parallel study on five volunteers to determine changes occurring in several trace compounds present in exhaled breath and emitted from skin into a collection bag surrounding part of the arm, before and after ingesting 75 g of glucose in the fasting state. SIFT-MS enabled real-time quantification of ammonia, methanol, ethanol, propanol, formaldehyde, acetaldehyde, isoprene and acetone. Following glucose ingestion, blood glucose and trace compound levels were measured every 30 min for 2 h. All the above compounds, except formaldehyde, were detected at the expected levels in exhaled breath of all volunteers; all the above compounds, except isoprene, were detected in the collection bag. Ammonia, methanol and ethanol were present at lower levels in the bag than in the breath. The aldehydes were present at higher levels in the bag than in breath. The blood glucose increased to a peak about 1 h post-ingestion, but this change was not obviously correlated with temporal changes in any of the compounds in breath or emitted by skin, except for acetone. The decrease in breath acetone was closely mirrored by skin-emitted acetone in three volunteers. Breath and skin acetone also clearly change with blood glucose and further work may ultimately enable inferences to be drawn of the blood glucose concentration from skin or breath measurements in type 1 diabetes.     

Exhaled breath condensate as a biomonitor for metal exposure: a new analytical challenge

The study of exhaled breath condensate (EBC) obtained by cooling exhaled air under conditions of spontaneous breathing is considered one of the areas with higher interest in respiratory health research. The use of EBC for elemental determination in occupational exposure requires a standard methodological procedure to implement its practice in occupational studies. EBC is an inhomogeneous sample with organic and particulate matter in suspension, which may hamper analytical results reliability. Total reflection X-ray fluorescence and inductive coupled-plasma mass spectrometry (ICP-MS) techniques were chosen as both are multielemental, require small sample volumes and have appropriate detection limits. Estimation of the overall uncertainty in both techniques was carried out using a pool of EBC collected from a group of workers of a lead processing industry to perform precision and trueness studies for K, Mn, Cu, Cd, Sb and Pb. Precision was estimated in terms of repeatability using the native EBC sample pool and trueness in terms of recovery obtained from spiking aliquots of the EBC pool with K, Mn, Cu, Cd, Sb and Pb at different concentrations. Recovery was the most significant contribution to total uncertainty. The overall uncertainties obtained for ICP-MS enabled to discriminate between groups of individuals exposed to different levels of contaminants. Therefore EBC proved to be useful in human biomonitoring.     

Simultaneous Determination of Hydrocortisone and Zn-Bacitracin by Spectrophotometric Derivative and Multivariate Methods

 Four spectrophotometric methods are described and applied to resolve binary mixtures of the corticosteroid hydrocortisone and the antibacterial polypeptide Zn-Bacitracin. The simultaneous determination of the two compounds was accomplished by means of derivative methods, which were satisfactory used to determine synthetic mixtures of these compounds in different ratios and in pharmaceutical preparations (only for hydrocortisone). Direct absorption spectra of compounds were used to optimise the spectral data set performs the calibration by PLS-1, PLS-2 and PCR algorithms. These calibration models were evaluated through internal validation (prediction of compounds in its own designed training set of calibration), cross-validation (obtaining statistical parameters that show the efficiency for a calibration fit model) and external validation over synthetic and pharmaceutical mixtures. The four described procedures do not require any separation step. Precision studies were achieved over two series of ten standards for each compound showing no significant differences at 95% confidence level in the two spectrophotometric methods. The results found in commercial products were compared with those obtained by means of MEKC method and similar values were found. Correspondence: Department of Analytical Chemistry and Food Technology, Universidad de Castilla-La Mancha, 13071 Ciudad Real, Spain. e-mail: JoseMaria.Lemus@uclm.es Received January 25, 2002; accepted October 22, 2002     

Use of polyurethane foam and 3-hydroxy-7,8-benzo-1,2,3,4-tetrahydroquinoline for determination of nitrite by diffuse reflectance spectroscopy and colorimetry

Polyurethane foam (PUF) has been suggested as a solid polymeric reagent for determination of nitrite. The determination is based on the diazotization of end toluidine groups of PUF with nitrite in acidic medium followed by coupling of polymeric diazonium cation with 3-hydroxy-7,8-benzo-1,2,3,4-tetrahydroquinoline. The intensely colored polymeric azodye formed in this reaction can be used as a convenient analytic form for the determination of nitrite by diffuse reflectance spectroscopy (c _min = 0.7 ng mL⁻¹). The possibility of using a desktop scanner, digital camera, and computer data processing for the numerical evaluation of the color intensity of the polymeric azodye has been investigated. A scanner and digital camera can be used for determination of nitrite with the same sensitivity and reproducibility as with diffuse reflectance spectroscopy. The approach developed was applied for determination of nitrite in river water and human exhaled breath condensate.     

Four-way calibration applied to the simultaneous determination of folic acid and methotrexate in urine samples

First-, second- and third-order calibration methods were investigated for the simultaneous determination of folic acid and methotrexate. The interest in the determination of these compounds is related to the fact that methotrexate inhibits the body’s absorption of folic acid and prolonged treatment with methotrexate may lead to folic acid deficiency, and to the use of folic acid to cope with toxic side effects of methotrexate. Both analytes were converted into highly fluorescent compounds by oxidation with potassium permanganate, and the kinetics of the reaction was continuously monitored by recording the kinetics curves of fluorescence emission, the evolution with time of the emission spectra and the excitation–emission matrices (EEMs) of the samples at different reaction times. Direct determination of mixtures of both drugs in urine was accomplished on the basis of the evolution of the kinetics of EEMs by fluorescence measurements and four-way parallel-factor analysis (PARAFAC) or multiway partial least squares (N-PLS) chemometric calibration. The core consistency diagnostic (CORCONDIA) was employed to determine the correct number of factors in PARAFAC and the procedure converged to a choice of three factors, attributed to folic acid, methotrexate and to the sum of fluorescent species present in the urine.      

Determination of N epsilon-(carboxymethyl)lysine in exhaled breath condensate using isotope dilution liquid chromatography/electrospray ionization tandem mass spectrometry

In order to identify new biomarkers for pulmonary diseases in exhaled breath condensate (EBC) it was the aim of this study to develop an analytical method for the identification and quantification of N epsilon-(carboxymethyl)lysine (CML) in EBC. As detection by liquid chromatography with positive electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) offers the advantage of structurally related detection with the necessary specificity required for the identification of a substance, it was the method chosen for the determination of the non-volatile compound. Specific mass transitions and comparison of retention times with standards under given conditions were used for the unequivocal identification of CML in EBC of healthy subjects. Synthesis of isotopically labelled CML was performed and used as an internal standard for an accurate determination. It was possible to identify the advanced glycation end-product CML in 8 out of 10 healthy subjects. The concentration range determined in the quantifiable examined samples ranged between 35 and 110 pg/mL. EBC samples from 11 patients with different diseases such as diabetes and chronic obstructive pulmonary disease were also measured. In one patient with pneumonia a concentration of 1509 pg CML/mL EBC could be detected. This is the first time that CML has been identified and determined in EBC. The developed LC/ESI-MS/MS method could be used to address the utility of CML as a biomarker in pulmonary diseases.     

Single‐breath analysis using a novel simple sampler and capillary electrophoresis with contactless conductometric detection

The analysis of ionic content of exhaled breath condensate (EBC) from one single breath by CE with C⁴D is demonstrated for the first time. A miniature sampler made from a 2‐mL syringe and an aluminum cooling cylinder for collection of EBC was developed. Various parameters of the sampler that influence its collection efficiency, repeatability, and effect of respiratory patterns were studied in detail. Efficient procedures for the cleanup of the miniature sampler were also developed and resulted in significant improvement of sampling repeatability. Analysis of EBC was performed by CE‐C⁴D in a 60 mM MES/l ‐histidine BGE with 30 μM CTAB and 2 mM 18‐crown‐6 at pH 6 and excellent repeatability of migration times (RSD < 1.3% (n = 7)) and peak areas (RSD < 7% (n = 7)) of 12 inorganic anions, cations, and organic acids was obtained. It has been shown that the breathing pattern has a significant impact on the concentration of the analytes in the collected EBC. As the ventilatory pattern can be easily controlled during single exhalation, the developed collection system and method provides a highly reproducible and fast way of collecting EBC with applicability in point‐of‐care diagnostics.