The challenge of breath analysis for clinical diagnosis and therapeutic monitoring

Assessing volatile organic compounds exposure and chronic obstructive pulmonary diseases in US adults

Background

Volatile organic compounds (VOCs) are a large group of chemicals widely used in People's Daily life. There is increasing evidence of the cumulative toxicity of VOCs. However, the association between VOCs and the risk of COPD has not been reported.

Objective

We comprehensively evaluated the association between VOCs and COPD.

Methods

Our study included a total of 1,477 subjects from the National Health and Nutrition Examination Survey, including VOCs, COPD, and other variables in the average US population. Multiple regression models and smooth-curve fitting (penalty splines) were constructed to examine potential associations, and stratified analyses were used to identify high-risk groups.

Results

We found a positive association between blood benzene and blood o-xylene concentrations and COPD risk and identified a concentration relationship between the two. That is, when the blood benzene and O-xylene concentrations reached 0.28 ng/mL and 0.08 ng/mL, respectively, the risk of COPD was the highest. In addition, we found that gender, age, and MET influence the relationship, especially in women, young people, and people with low MET.

Significance

This study revealed that blood benzene and blood o-xylene were independently and positively correlated with COPD risk, suggesting that long-term exposure to benzene and O-xylene may cause pulmonary diseases, and providing a new standard of related blood VOCs concentration for the prevention of COPD.

Amplified Photothermal Phase Modulation for Carbon Dioxide Detection by Operating a Dual-Mode Interferometer at Destructive Interference

Photothermal interferometry is a highly sensitive spectroscopic technique for trace gas detection. However, the performance of the state-of-the-art laser spectroscopic sensors is still insufficient for some high-precision applications. Here, we demonstrate optical phase-modulation amplification by operating a dual-mode optical fiber interferometer at destructive interference for ultrasensitive carbon dioxide detection. With a 50 cm long dual-mode hollow-core fiber, amplification of photothermal phase modulation by a factor of nearly 20 is achieved, which enables carbon dioxide detection down to 1 parts-per-billion with a dynamic range of over 7 orders of magnitude. This technique could be readily used to improve the sensitivity of phase modulation-based sensors with a compact and simple configuration.

Common Strategies and Factors Affecting Off-Line Breath Sampling and Volatile Organic Compounds Analysis Using Thermal Desorption-Gas Chromatography-Mass Spectrometry (TD-GC-MS)

An analysis of exhaled breath enables specialists to noninvasively monitor biochemical processes and to determine any pathological state in the human body. Breath analysis holds the greatest potential to remold and personalize diagnostics; however, it requires a multidisciplinary approach and collaboration of many specialists. Despite the fact that breath is considered to be a less complex matrix than blood, it is not commonly used as a diagnostic and prognostic tool for early detection of disordered conditions due to its problematic sampling, analysis, and storage. This review is intended to determine, standardize, and marshal experimental strategies for successful, reliable, and especially, reproducible breath analysis.

Volatile Organic Compounds Analysis as a Potential Novel Screening Tool for Breast Cancer: A Systematic Review

Introduction

An early diagnosis is crucial in reducing mortality among people who have breast cancer (BC). There is a shortfall of characteristic early clinical symptoms in BC patients, highlighting the importance of investigating new methods for its early detection. A promising novel approach is the analysis of volatile organic compounds (VOCs) produced and emitted through the metabolism of cancer cells.

Methods

The purpose of this systematic review is to outline the published research regarding BC-associated VOCs. For this, headspace analysis of VOCs was explored in patient-derived body fluids, animal model-derived fluids, and BC cell lines to identify BC-specific VOCs. A systematic search in PubMed and Web of Science databases was conducted according to the PRISMA guidelines.

Results

Thirty-two studies met the criteria for inclusion in this review. Results highlight that VOC analysis can be promising as a potential novel screening tool. However, results of in vivo, in vitro and case-control studies have delivered inconsistent results leading to a lack of inter-matrix consensus between different VOC sampling methods.

Discussion

Discrepant VOC results among BC studies have been obtained, highly due to methodological discrepancies. Therefore, methodological issues leading to disparities have been reviewed and recommendations have been made on the standardisation of VOC collection and analysis methods for BC screening, thereby improving future VOC clinical validation studies.

Breathomics for the clinician: the use of volatile organic compounds in respiratory diseases

Exhaled breath analysis has the potential to provide valuable insight on the status of various metabolic pathways taking place in the lungs locally and other vital organs, via systemic circulation. For years, volatile organic compounds (VOCs) have been proposed as feasible alternative diagnostic and prognostic biomarkers for different respiratory pathologies.We reviewed the currently published literature on the discovery of exhaled breath VOCs and their utilisation in various respiratory diseasesKey barriers in the development of clinical breath tests include the lack of unified consensus for breath collection and analysis and the complexity of understanding the relationship between the exhaled VOCs and the underlying metabolic pathways. We present a comprehensive overview, in light of published literature and our experience from coordinating a national breathomics centre, of the progress made to date and some of the key challenges in the field and ways to overcome them. We particularly focus on the relevance of breathomics to clinicians and the valuable insights it adds to diagnostics and disease monitoring.Breathomics holds great promise and our findings merit further large-scale multicentre diagnostic studies using standardised protocols to help position this novel technology at the centre of respiratory disease diagnostics.

Binary Gas Analyzer Based on a Single Gold Nanoparticle Photothermal Response

Although thermal conductivity gas analyzers are ubiquitous in industry, shrinking the sensing unit to a microscopic scale is rarely achieved. Since heat transfer between a metal nanoparticle and its ambient gas changes the temperature, refractive index, and density of the gaseous surrounding, one may tackle the problem using a single nanoparticle's photothermal effect. Upon heating by a 532 nm laser, a single gold nanoparticle transfers heat to the surrounding gas environment, which results in a change in the photothermal polarization of a 633 nm probe laser. The amplitude of the photothermal signal correlates directly with the concentration of binary gas mixture. In He/Ar, He/N₂, He/air, and H₂/Ar binary gas mixtures, the signal is linearly proportional to the He and H₂ molar concentrations up to about 10%. The photothermal response comes from the microscopic gaseous environment of a single gold nanoparticle, extending from the nanoparticle roughly to the length of the gas molecule's mean free path. This study points to a way of sensing binary gas composition in a microscopic volume using a single metal nanoparticle.

Comparison of the effect of chemically and biologically induced inflammation on the volatile metabolite production of lung epithelial cells by GC×GC-TOFMS

Exhaled breath analysis has a high potential for early non-invasive diagnosis of lung inflammatory diseases, such as asthma. The characterization and understanding of the inflammatory metabolic pathways involved into volatile organic compounds (VOCs) production could bring exhaled breath analysis into clinical practice and thus open new therapeutic routes for inflammatory diseases. In this study, lung inflammation was simulated in vitro using A549 epithelial cells. We compared the VOC production from A549 epithelial cells after a chemically induced oxidative stress in vitro, exposing the cells to H₂O₂, and a biological stress, exposing the cells to an inflammatory pool of sputum supernatants. Special attention was devoted to define proper negative and positive controls (8 different types) for our in vitro models, including healthy sputum co-culture. Sputum from 25 asthmatic and 8 healthy patients were collected to create each pool of supernatants. Each sample type was analyzed in 4 replicates using solid-phase microextraction (SPME) comprehensive two-dimensional gas chromatography hyphenated to time-of-flight mass spectrometry (GC×GC-TOFMS). This approach offers high resolving power for complex VOC mixtures. According to the type of inflammation induced, significantly different VOCs were produced by the epithelial cells compared to all controls. For both chemical and biological challenges, an increase of carbonyl compounds (54%) and hydrocarbons (31%) was observed. Interestingly, only the biological inflammation model showed a significant cell proliferation together with an increased VOC production linked to asthma airway inflammation. This study presents a complete GC×GC-TOFMS workflow for in vitro VOC analysis, and its potential to characterize complex lung inflammatory mechanisms.

Hollow-Core Photonic Crystal Fiber Gas Sensing

Fiber gas sensing techniques have been applied for a wide range of industrial applications. In this paper, the basic fiber gas sensing principles and the development of different fibers have been introduced. In various specialty fibers, hollow-core photonic crystal fibers (HC-PCFs) can overcome the fundamental limits of solid fibers and have attracted intense interest recently. Here, we focus on the review of HC-PCF gas sensing, including the light-guiding mechanisms of HC-PCFs, various sensing configurations, microfabrication approaches, and recent research advances including the mid-infrared gas sensors via hollow core anti-resonant fibers. This review gives a detailed and deep understanding of HC-PCF gas sensors and will promote more practical applications of HC-PCFs in the near future.

Mode-phase-difference photothermal spectroscopy for gas detection with an anti-resonant hollow-core optical fiber

Laser spectroscopy outperforms electrochemical and semiconductor gas sensors in selectivity and environmental survivability. However, the performance of the state-of-the-art laser sensors is still insufficient for many high precision applications. Here, we report mode-phase-difference photothermal spectroscopy with a dual-mode anti-resonant hollow-core optical fiber and demonstrate all-fiber gas (acetylene) detection down to ppt (parts-per-trillion) and <1% instability over a period of 3 hours. An anti-resonant hollow-core fiber could be designed to transmit light signals over a broad wavelength range from visible to infrared, covering molecular absorption lines of many important gases. This would enable multi-component gas detection with a single sensing element and pave the way for ultra-precision gas sensing for medical, environmental and industrial applications.

Typically, the performance of the state-of-the-art laser sensors is insufficient for many high precision applications. Here, the authors report mode-phase-difference photothermal spectroscopy with a dual-mode anti-resonant hollow-core optical fiber and demonstrate acetylene detection with ultra-high sensitivity.

Quartz-enhanced photoacoustic sensor for ethylene detection implementing optimized custom tuning fork-based spectrophone

The design and realization of two highly sensitive and easily interchangeable spectrophones based on custom quartz tuning forks, with a rectangular (S₁) or T-shaped (S₂) prongs geometry, is reported. The two spectrophones have been implemented in a QEPAS sensor for ethylene detection, employing a DFB-QCL emitting at 10.337 μm with an optical power of 74.2 mW. A comparison between their performances showed a signal-to-noise ratio 3.4 times higher when implementing the S₂ spectrophone. For the S₂-based sensor, a linear dependence of the QEPAS signal on ethylene concentration was demonstrated in the 5 ppm -100 ppm range. For a 10 s lock-in integration time, an ethylene minimum detection limit of 10 ppb was calculated.

Effects of humidity, CO2 and O2 on real-time quantitation of breath biomarkers by means of PTR-ToF-MS

Proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS) represents an attractive tool for the real-time analysis of VOC profiles in human breath. Quantification of breath VOCs by means of direct MS may be affected by the matrix, as human breath not only contains several hundred VOCs at the ppbV-pptV level, but is water saturated and contains percentage levels of CO₂. Investigation of breath biomarkers in clinical studies requires quantitative and comparable results. We therefore systematically assessed the effect of humidity, CO₂ and O₂ on the results of PTR-MS analysis. We investigated more than 20 VOCs, including aldehydes, ketones, aromatic compounds and hydrocarbons with different sample humidity, CO₂ and O₂ content. The influence of data processing (e.g. normalization to the H₃O⁺ ion count) was also addressed. An increase of the H₃O⁺ count of about 20% was observed when the humidity in the sample was increased to breath levels. Large differences regarding the measured VOC intensities were found between the dry and humid samples. Data normalization to the H₃O⁺ or water-clusters could not fully compensate for the humidity-dependent effects. However, as the determination of most VOCs linearly depends on the humidity over the whole investigated range, factor-based correction seems possible. The effects of CO₂ were more pronounced in the dry samples than in the humid samples but only had a minor influence on the results. The same was true for the influence of O₂. For the reliable quantification of VOCs in clinical studies and for the standardization of VOC research, well-adapted calibration standards are required for PTR-MS analysis.

Air sampling unit for breath analyzers

The paper presents a portable breath sampling unit (BSU) for human breath analyzers. The developed unit can be used to probe air from the upper airway and alveolar for clinical and science studies. The BSU is able to operate as a patient interface device for most types of breath analyzers. Its main task is to separate and to collect the selected phases of the exhaled air. To monitor the so-called I, II, or III phase and to identify the airflow from the upper and lower parts of the human respiratory system, the unit performs measurements of the exhaled CO₂ (ECO₂) in the concentration range of 0%-20% (0-150 mm Hg). It can work in both on-line and off-line modes according to American Thoracic Society/European Respiratory Society standards. A Tedlar bag with a volume of 5 dm³ is mounted as a BSU sample container. This volume allows us to collect ca. 1-25 selected breath phases. At the user panel, each step of the unit operation is visualized by LED indicators. This helps us to regulate the natural breathing cycle of the patient. There is also an operator's panel to ensure monitoring and configuration setup of the unit parameters. The operation of the breath sampling unit was preliminarily verified using the gas chromatography/mass spectrometry (GC/MS) laboratory setup. At this setup, volatile organic compounds were extracted by solid phase microextraction. The tests were performed by the comparison of GC/MS signals from both exhaled nitric oxide and isoprene analyses for three breath phases. The functionality of the unit was proven because there was an observed increase in the signal level in the case of the III phase (approximately 40%). The described work made it possible to construct a prototype of a very efficient breath sampling unit dedicated to breath sample analyzers.

Possible photoacoustic gas detection for a smart endoscope

Endogenous gas analysis is a potentially fast and convenient noninvasive diagnostic method for a variety of diseases. However, sampling and sample preparation are error-prone steps and must be optimized to achieve reliable results. A miniature photoacoustic system was developed to allow gas sampling using a smart endoscope. The photoacoustic system was demonstrated to have a 1% detection limit for CO2, which is too high. Many improvements, including modifying the structure of PA cell, must be considered for further development.

Exhaled isopropanol: new potential biomarker in diabetic breathomics and its metabolic correlations with acetone

Concomitant findings of acetone (ACE) and isopropanol (IPA) in blood and other biological samples have been reported in diabetic decedents and clinic cases, but exhaled IPA has rarely been studied in breath research.

The Measurement of Ammonia in Human Breath and its Potential in Clinical Diagnostics

Ammonia is an important component of metabolism and is involved in many physiological processes. During normal physiology, levels of blood ammonia are between 11 and 50 µM. Elevated blood ammonia levels are associated with a variety of pathological conditions such as liver and kidney dysfunction, Reye's syndrome and a variety of inborn errors of metabolism including urea cycle disorders (UCD), organic acidaemias and hyperinsulinism/hyperammonaemia syndrome in which ammonia may reach levels in excess of 1 mM. It is highly neurotoxic and so effective measurement is critical for assessing and monitoring disease severity and treatment. Ammonia is also a potential biomarker in exercise physiology and studies of drug metabolism. Current ammonia testing is based on blood sampling, which is inconvenient and can be subject to significant analytical errors due to the quality of the sample draw, its handling and preparation for analysis. Blood ammonia is in gaseous equilibrium with the lungs. Recent research has demonstrated the potential use of breath ammonia as a non-invasive means of measuring systemic ammonia. This requires measurement of ammonia in real breath samples with associated temperature, humidity and gas characteristics at concentrations between 50 and several thousand parts per billion. This review explores the diagnostic applications of ammonia measurement and the impact that the move from blood to breath analysis could have on how these processes and diseases are studied and managed.

Detection of volatile organic compounds (VOCs) from exhaled breath as noninvasive methods for cancer diagnosis

The detection of cancer at an early stage is often significant in the successful treatment of the disease. Tumor cells have been reported to generate unique cancer volatile organic compound (VOC) profiles which can reflect the disease conditions. The detection and analysis of VOC biomarkers from exhaled breath has been recognized as a new frontier in cancer diagnostics and health inspections owing to its potential in developing rapid, noninvasive, and inexpensive cancer screening tools. To detect specific VOCs of low concentrations from exhaled breath, and to enhance the accuracy of early diagnosis, many breath collection and analysis approaches have been developed. This paper will summarize and critically review the exhaled-breath VOC-related sampling, collection, detection, and analytical methods, especially the recent development in VOC sensors. VOC sensors are commonly inexpensive, portable, programmable, easy to use, and can obtain data in real time with high sensitivities. Therefore, many sensor-based VOC detection techniques have huge potential in clinical point-of-care use.

Single mode thermal emission

We report on the properties of a thermal emitter which radiates into a single mode waveguide. We show that the maximal power of thermal radiation into a propagating single mode is limited only by the temperature of the thermal emitter and does not depend on other parameters of the waveguide. Furthermore, we show that the power of the thermal emitter cannot be increased by resonant coupling. For a given temperature, the enhancement of the total emitted power is only possible if the number of excited modes is increased. Either a narrowband or a broadband thermal excitation of the mode is possible, depending on the properties of the emitter. We finally discuss an example system, namely a thermal source for silicon photonics.

Analysis of Exhaled Breath Volatile Organic Compounds in Inflammatory Bowel Disease: A Pilot Study

BACKGROUND AND AIMS

Distinguishing between the inflammatory bowel diseases [IBD], Crohn's disease [CD] and ulcerative colitis [UC], is important for determining management and prognosis. Selected ion flow tube mass spectrometry [SIFT-MS] may be used to analyse volatile organic compounds [VOCs] in exhaled breath: these may be altered in disease states, and distinguishing breath VOC profiles can be identified. The aim of this pilot study was to identify, quantify, and analyse VOCs present in the breath of IBD patients and controls, potentially providing insights into disease pathogenesis and complementing current diagnostic algorithms.

METHODS

SIFT-MS breath profiling of 56 individuals [20 UC, 18 CD, and 18 healthy controls] was undertaken. Multivariate analysis included principal components analysis and partial least squares discriminant analysis with orthogonal signal correction [OSC-PLS-DA]. Receiver operating characteristic [ROC] analysis was performed for each comparative analysis using statistically significant VOCs.

RESULTS

OSC-PLS-DA modelling was able to distinguish both CD and UC from healthy controls and from one other with good sensitivity and specificity. ROC analysis using combinations of statistically significant VOCs [dimethyl sulphide, hydrogen sulphide, hydrogen cyanide, ammonia, butanal, and nonanal] gave integrated areas under the curve of 0.86 [CD vs healthy controls], 0.74 [UC vs healthy controls], and 0.83 [CD vs UC].

CONCLUSIONS

Exhaled breath VOC profiling was able to distinguish IBD patients from controls, as well as to separate UC from CD, using both multivariate and univariate statistical techniques.

Mitoxantrone, More than Just Another Topoisomerase II Poison

Mitoxantrone is a synthetic anthracenedione originally developed to improve the therapeutic profile of the anthracyclines and is commonly applied in the treatment of breast and prostate cancers, lymphomas, and leukemias. A comprehensive overview of the drug's molecular, biochemical, and cellular pharmacology is presented here, beginning with the cardiotoxic nature of its predecessor doxorubicin and how these properties shaped the pharmacology of mitoxantrone itself. Although mitoxantrone is firmly established as a DNA topoisomerase II poison within mammalian cells, it is now clear that the drug interacts with a much broader range of biological macromolecules both covalently and noncovalently. Here, we consider each of these interactions in the context of their wider biological relevance to cancer therapy and highlight how they may be exploited to further enhance the therapeutic value of mitoxantrone. In doing so, it is now clear that mitoxantrone is more than just another topoisomerase II poison.

Advances in electronic-nose technologies for the detection of volatile biomarker metabolites in the human breath

Recent advancements in the use of electronic-nose (e-nose) devices to analyze human breath profiles for the presence of specific volatile metabolites, known as biomarkers or chemical bio-indicators of specific human diseases, metabolic disorders and the overall health status of individuals, are providing the potential for new noninvasive tools and techniques useful to point-of-care clinical disease diagnoses. This exciting new area of electronic disease detection and diagnosis promises to yield much faster and earlier detection of human diseases and disorders, allowing earlier, more effective treatments, resulting in more rapid patient recovery from various afflictions. E-nose devices are particularly suited for the field of disease diagnostics, because they are sensitive to a wide range of volatile organic compounds (VOCs) and can effectively distinguish between different complex gaseous mixtures via analysis of electronic aroma sensor-array output profiles of volatile metabolites present in the human breath. This review provides a summary of some recent developments of electronic-nose technologies, particularly involving breath analysis, with the potential for providing many new diagnostic applications for the detection of specific human diseases associated with different organs in the body, detectable from e-nose analyses of aberrant disease-associated VOCs present in air expired from the lungs.

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.

Investigation of C3-C10 aldehydes in the exhaled breath of healthy subjects using selected ion flow tube-mass spectrometry (SIFT-MS)

Aldehydes have attracted great scientific and clinical interest as potential disease biomarkers. We have investigated selected ion flow tube-mass spectrometry (SIFT-MS) in detecting and quantifying C3 to C10 saturated aldehydes (propanal, butanal, pentanal, hexanal, heptanal, octanal, nonanal and decanal) from the exhaled breath of 26 healthy human volunteers. To assess the reliability of the Nalophan® bag sampling method employed, the water level in the breath sample was measured up to 4 h after collection and showed no significant degradation. Propanal was found to be the most abundant aldehyde in the exhaled breath of healthy volunteers. For the C4-C10 aldehydes, their median concentrations were all less than 3 ppbv, demonstrating only trace quantities are present in the exhaled breath of the 26 healthy volunteers.

Breath analysis in disease diagnosis: methodological considerations and applications

Breath analysis is a promising field with great potential for non-invasive diagnosis of a number of disease states. Analysis of the concentrations of volatile organic compounds (VOCs) in breath with an acceptable accuracy are assessed by means of using analytical techniques with high sensitivity, accuracy, precision, low response time, and low detection limit, which are desirable characteristics for the detection of VOCs in human breath. "Breath fingerprinting", indicative of a specific clinical status, relies on the use of multivariate statistics methods with powerful in-built algorithms. The need for standardisation of sample collection and analysis is the main issue concerning breath analysis, blocking the introduction of breath tests into clinical practice. This review describes recent scientific developments in basic research and clinical applications, namely issues concerning sampling and biochemistry, highlighting the diagnostic potential of breath analysis for disease diagnosis. Several considerations that need to be taken into account in breath analysis are documented here, including the growing need for metabolomics to deal with breath profiles.

Solid-state gas sensors for breath analysis: a review

The analysis of volatile compounds is an efficient method to appraise information about the chemical composition of liquids and solids. This principle is applied to several practical applications, such as food analysis where many important features (e.g. freshness) can be directly inferred from the analysis of volatile compounds. The same approach can also be applied to a human body where the volatile compounds, collected from the skin, the breath or in the headspace of fluids, might contain information that could be used to diagnose several kinds of diseases. In particular, breath is widely studied and many diseases can be potentially detected from breath analysis. The most fascinating property of breath analysis is the non-invasiveness of the sample collection. Solid-state sensors are considered the natural complement to breath analysis, matching the non-invasiveness with typical sensor features such as low-cost, easiness of use, portability, and the integration with the information networks. Sensors based breath analysis is then expected to dramatically extend the diagnostic capabilities enabling the screening of large populations for the early diagnosis of pathologies. In the last years there has been an increased attention to the development of sensors specifically aimed to this purpose. These investigations involve both specific sensors designed to detect individual compounds and non-specific sensors, operated in array configurations, aimed at clustering subjects according to their health conditions. In this paper, the recent significant applications of these sensors to breath analysis are reviewed and discussed.

Ultrafast response humidity sensor using supramolecular nanofibre and its application in monitoring breath humidity and flow

Measuring humidity in dynamic situations calls for highly sensitive fast response sensors. Here we report, a humidity sensor fabricated using solution processed supramolecular nanofibres as active resistive sensing material. The nanofibres are built via self- assembly of donor and acceptor molecules (coronene tetracarboxylate and dodecyl methyl viologen respectively) involved in charge transfer interactions. The conductivity of the nanofibre varied sensitively over a wide range of relative humidity (RH) with unprecedented fast response and recovery times. Based on UV-vis, XRD and AFM measurements, it is found that the stacking distance in the nanofibre decreases slightly while the charge transfer band intensity increases, all observations implying enhanced charge transfer interaction and hence the conductivity. It is demonstrated to be as a novel breath sensor which can monitor the respiration rate. Using two humidity sensors, a breath flow sensor was made which could simultaneously measure RH and flow rate of exhaled nasal breath. The integrated device was used for monitoring RH in the exhaled breath from volunteers undergoing exercise and alcohol induced dehydration.

Clinical application of volatile organic compound analysis for detecting infectious diseases

This review article introduces the significance of testing of volatile organic compounds (VOCs) in clinical samples and summarizes important features of some of the technologies. Compared to other human diseases such as cancer, studies on VOC analysis in cases of infectious diseases are limited. Here, we have described results of studies which have used some of the appropriate technologies to evaluate VOC biomarkers and biomarker profiles associated with infections. The publications reviewed include important infections of the respiratory tract, gastrointestinal tract, urinary tract, and nasal cavity. The results highlight the use of VOC biomarker profiles resulting from certain infectious diseases in discriminating between infected and healthy subjects. Infection-related VOC profiles measured in exhaled breath as well as from headspaces of feces or urine samples are a source of information with respect to disease detection. The volatiles emitted in clinical matrices may on the one hand represent metabolites of the infecting pathogen or on the other hand reflect pathogen-induced host responses or, indeed, a combination of both. Because exhaled-breath samples are easy to collect and online instruments are commercially available, VOC analysis in exhaled breath appears to be a promising tool for noninvasive detection and monitoring of infectious diseases.

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.

Detection of volatile organic compounds as biomarkers in breath analysis by different analytical techniques

Breath is a rich mixture containing numerous volatile organic compounds at trace amounts (ppbv–pptv level) such as: hydrocarbons, alcohols, ketones, aldehydes, esters or heterocycles. The presence of some of them depends on health status. Therefore, breath analysis might be useful for clinical diagnostics, therapy monitoring and control of metabolic or biochemical cell cycle products. This Review presents an update on the latest developments in breath analysis applied to diagnosing different diseases with the help of high-quality equipment. Efforts were made to fully and accurately describe traditional and modern techniques used to determine the components of breath. The techniques were compared in terms of design, function and also detection limit of different volatile organic compounds. GC with different detectors, MS, optical sensor and laser spectroscopic detection techniques are also discussed.

Selected ion flow tube mass spectrometry analysis of volatile metabolites in urine headspace for the profiling of gastro-esophageal cancer

Urine is considered an ideal biofluid for clinical investigation because it is obtained noninvasively and relatively large volumes are easily acquired. In this study, selected ion flow tube mass spectrometry (SIFT-MS) has been applied for the quantification of volatile organic compounds (VOCs) in the headspace vapor of urine samples, which were retrieved from three groups of patients with gastro-esophageal cancer, noncancer diseases of the upper gastro-intestinal tract, and a healthy cohort. Eleven VOCs have been investigated in this study. The concentrations of seven VOCs-acetaldehyde, acetone, acetic acid, hexanoic acid, hydrogen sulfide, methanol, and phenol-were found to be significantly different between cancer, positive control, and healthy groups using the Kruskal-Wallis test. The concentrations of acetaldehyde, acetone, acetic acid, hexanoic acid, hydrogen sulfide, and methanol were increased in the cancer cohort compared with healthy controls while the concentration of phenol decreased. The differences in the concentrations of ethanol, propanol, methyl phenol, and ethyl phenol were not significant between cancer and control groups. Receiver operating characteristics (ROC) analysis was applied for a combination of six VOCs (acetaldehyde, acetone, acetic acid, hexanoic acid, hydrogen sulfide, and methanol) to discriminate cancer patients from noncancer controls. The integrated area under ROC curve is 0.904. This result indicates that VOC profiling may be suitable in identifying those at high risk of gastro-esophageal cancer. Therefore, further investigations should be undertaken to assess the potential for VOC profiling as a new screening test in gastro-esophageal cancer.

Real-time clinical monitoring of biomolecules

Continuous monitoring of clinical biomarkers offers the exciting possibility of new therapies that use biomarker levels to guide treatment in real time. This review explores recent progress toward this goal. We initially consider measurements in body fluids by a range of analytical methods. We then discuss direct tissue measurements performed by implanted sensors; sampling techniques, including microdialysis and ultrafiltration; and noninvasive methods. A future directions section considers analytical methods at the cusp of clinical use.

Selected ion flow tube-MS analysis of headspace vapor from gastric content for the diagnosis of gastro-esophageal cancer

Gastric content is a complex biofluid within the human stomach which has an important role in digestive processes. It is believed that gastric content may be a contributory factor in the development of upper gastro-intestinal diseases. In this work, selected ion flow tube mass spectrometry (SIFT-MS) has been applied to the quantification of volatile organic compounds (VOCs) in the headspace vapor of gastric content samples, which were retrieved from three groups of patients, including those with gastro-esophageal cancer, noncancer diseases of the upper gastro-intestinal tract, and a healthy cohort. Twelve VOCs have been investigated in this study; the following 7 VOCs, acetone, formaldehyde, acetaldehyde, hexanoic acid, hydrogen sulphide, hydrogen cyanide, and methyl phenol, were found to be significantly different between cancer and healthy groups by the Mann-Whitney U test. Receiver operating characteristics (ROC) analysis was applied for the combined VOCs of acetaldehyde, formaldehyde, hydrogen sulphide, and methyl phenol to discriminate cancer patients from healthy controls. The area under the curve (AUC) was 0.9. This result raises the prospect that a VOC profile rather than a single biomarker may be preferable in the molecular-orientated diagnosis of gastro-oseophageal cancer, and this warrants further investigation to assess its potential application as a new diagnostic test.

Cardiovascular biomarkers in exhaled breath

With each breath that we exhale, thousands of molecules are expelled in our breath, giving individuals a "breath-print" that can tell a lot about them and their state of health. Breath analysis is rapidly evolving as the new frontier in medical testing. The end of the 20th century and the beginning of the 21st century have arguably witnessed a revolution in our understanding of the constituents of exhaled breath and the development of the field of breath analysis and testing. Thanks to major breakthroughs in new technologies (infrared, electrochemical, chemiluminescence, and others) and the availability of mass spectrometers, the field of breath analysis has made considerable advances in the 21st century. Several methods are now in clinical use or nearly ready to enter that arena. Breath analysis has the potential to offer relatively inexpensive, rapid, noninvasive methods for detecting and/or monitoring a variety of diseases. Breath analysis also has applications in fields beyond medicine, including environmental monitoring, security, and others. This review will focus on exhaled breath as a potential source of biomarkers for medical applications with specific attention to applications (and potential applications) in cardiovascular disease.

A workflow for the metabolomic/metabonomic investigation of exhaled breath using thermal desorption GC–MS

Background: Confounding factors in the analysis of human breath by thermal desorption GC–MS are reviewed, with special emphasis on the high water levels encountered in human breath samples. Results: Multilinear regression optimization of breath sampling factors, along with the selection of ubiquitous sample components used as retention-time standards, enabled data registration based on retention indexing and mass spectral alignment. This was done on a component-by-component basis. The methodology developed reconciled participant safety, artefacts from accelerated hydrolysis of the stationary phase and the destructive nature of thermal desorption. Furthermore, using ubiquitous methylated cyclic-siloxanes in the thermal desorption-GC–MS chromatograms enabled secondary retention indexing for each chromatogram. This methodology enables the creation of a ‘breath matrix’ that is based on a combination of retention indexing and the mass spectral registration of isolated peaks. Conclusion: This approach facilitated more efficient data modeling and a case study from a 22-participant (10 male, 12 female) stress-intervention experiment. Principal component analysis of data registered by retention indexing did not classify successfully stressed from unstressed states. By contrast, adoption of a breath matrix approach enabled 95% separation.

Cardiovascular biomarkers in exhaled breath

With each breath that we exhale, thousands of molecules are expelled in our breath, giving individuals a "breath-print" that can tell a lot about them and their state of health. Breath analysis is rapidly evolving as the new frontier in medical testing. The end of the 20th century and the beginning of the 21st century have arguably witnessed a revolution in our understanding of the constituents of exhaled breath and the development of the field of breath analysis and testing. Thanks to major breakthroughs in new technologies (infrared, electrochemical, chemiluminescence, and others) and the availability of mass spectrometers, the field of breath analysis has made considerable advances in the 21st century. Several methods are now in clinical use or nearly ready to enter that arena. Breath analysis has the potential to offer relatively inexpensive, rapid, noninvasive methods for detecting and/or monitoring a variety of diseases. Breath analysis also has applications in fields beyond medicine, including environmental monitoring, security, and others. This review will focus on exhaled breath as a potential source of biomarkers for medical applications with specific attention to applications (and potential applications) in cardiovascular disease.

Influence of age and sex in exhaled breath samples investigated by means of infrared laser absorption spectroscopy

Breath gas analysis provides insight into human metabolism of healthy and ill individuals. As an innovative and non-invasive method, it opens up options to improve diagnostics, monitoring and treatment decisions. Mid-infrared laser absorption spectroscopy is utilized to detect CH(4), H(2)O, CO(2), NH(3) and CH(3)OH in exhaled human breath. An off-line approach using breath sampling by means of Tedlar bags is applied. The breath gas samples are measured within the population-based epidemiological Study of Health in Pomerania (SHIP-TREND) performed at the University of Greifswald. The study covers about 5000 adult subjects aged 20-79 years within 3 years. Besides breath gas analysis many other examinations are conducted. It is expected to find associations between distinct concentration levels of species in the exhaled breath and diseases assessed in this study. The study will establish reference values for exhaled breath components and serve as background population for case-control studies. In the long run, morbidity and mortality follow-ups will be conducted, which will answer the question whether end-expiratory breath gas components predict future diseases and death. As first results, we present data from 45 dialysis patients (23 males, 22 females) which were recruited in a preliminary study in preparation for SHIP-TREND.

Ambient analysis of trace compounds in gaseous media by SIFT-MS

The topic of ambient gas analysis has been rapidly developed in the last few years with the evolution of the exciting new techniques such as DESI, DART and EESI. The essential feature of all is that analysis of trace gases can be accomplished either in the gas phase or those released from surfaces, crucially avoiding sample collection or modification. In this regard, selected ion flow tube mass spectrometry, SIFT-MS, also performs ambient analyses both accurately and rapidly. In this focused review we describe the underlying ion chemistry underpinning SIFT-MS through a discourse on the reactions of different classes of organic and inorganic molecules with H(3)O(+), NO(+) and O(2)(+)˙ studied using the SIFT technique. Rate coefficients and ion products of these reactions facilitate absolute SIFT-MS analyses and can also be useful for the interpretation of data obtained by the other ambient analysis methods mentioned above. The essential physics and flow dynamics of SIFT-MS are described that, together with the reaction kinetics, allow SIFT-MS to perform absolute ambient analyses of trace compounds in humid atmospheric air, exhaled breath and the headspace of aqueous liquids. Several areas of research that, through pilot experiments, are seen to benefit from ambient gas analysis using SIFT-MS are briefly reviewed. Special attention is given to exhaled breath and urine headspace analysis directed towards clinical diagnosis and therapeutic monitoring, and some other areas researched using SIFT-MS are summarised. Finally, extensions to current areas of application and indications of other directions in which SIFT-MS can be exploited for ambient analysis are alluded to.

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.