Real-time breath analysis towards a healthy human breath profile

The direct analysis of molecules contained within human breath has had significant implications for clinical and diagnostic applications in recent decades. However, attempts to compare one study to another or to reproduce previous work are hampered by: variability between sampling methodologies, human phenotypic variability, complex interactions between compounds within breath, and confounding signals from comorbidities. Towards this end, we have endeavored to create an averaged healthy human 'profile' against which follow-on studies might be compared. Through the use of direct secondary electrospray ionization combined with a high-resolution mass spectrometry and in-house bioinformatics pipeline, we seek to curate an average healthy human profile for breath and use this model to distinguish differences inter- and intra-day for human volunteers. Breath samples were significantly different in PERMANOVA analysis and ANOSIM analysis based on Time of Day, Participant ID, Date of Sample, Sex of Participant, and Age of Participant (p< 0.001). Optimal binning analysis identify strong associations between specific features and variables. These include 227 breath features identified as unique identifiers for 28 of the 31 participants. Four signals were identified to be strongly associated with female participants and one with male participants. A total of 37 signals were identified to be strongly associated with the time-of-day samples were taken. Threshold indicator taxa analysis indicated a shift in significant breath features across the age gradient of participants with peak disruption of breath metabolites occurring at around age 32. Forty-eight features were identified after filtering from which a healthy human breath profile for all participants was created.

Direct mass spectrometry analysis of exhaled human breath in real-time

The molecular composition of exhaled human breath can reflect various physiological and pathological conditions. Considerable progress has been achieved over the past decade in real-time analysis of exhaled human breath using direct mass spectrometry methods, including selected ion flow tube mass spectrometry, proton transfer reaction mass spectrometry, extractive electrospray ionization mass spectrometry, secondary electrospray ionization mass spectrometry, acetone-assisted negative photoionization mass spectrometry, atmospheric pressure photoionization mass spectrometry, and low-pressure photoionization mass spectrometry. Here, recent developments in direct mass spectrometry analysis of exhaled human breath are reviewed with regard to analytical performance (chemical sensitivity, selectivity, quantitative capabilities) and applications of the developed methods in disease diagnosis, targeted molecular detection, and real-time metabolic monitoring.

High-resolution mass spectrometry exhalome profiling with a modified direct analysis in real time ion source

RATIONALE

Exhaled breath contains many substances that are closely related to human metabolism. Analysis of its composition is important for human health, but it is difficult. Since the volatile molecules in breath samples are exhaled instantaneously, easily diffused and modified, and at low level of presence, they are difficult to identify and quantify.

METHODS

A modified direct analysis in real time ion source was used for high-resolution mass spectrometry measurement of human metabolites in exhaled breath through online monitoring and offline analysis, in both positive and negative ion modes. The improved system enabled the breath volatiles as well as condensates to be directly sampled, rapidly transmitted and efficiently ionized in a confined region, and then detected using an Orbitrap mass analyzer.

RESULTS

The molecular features with online and offline analysis of exhaled breath were demonstrated with obvious differences. A total of about 65 metabolites in positive ion mode and about 55 metabolites in negative ion mode were identified based on accurate m/z values. Exhalome profile and the composition proportion of different classes of compounds were obtained. The relative contents of metabolites from breath varied during different time periods throughout a day.

CONCLUSIONS

A more complete picture of the human breath metabolome was provided combining the results obtained from both online and offline analysis. The developed method allows analysis of breath samples with different status rapidly and directly, and it features simple operation and metabolite identification, requiring little or no sample preparation.

Effects of a Volatile Organic Compound Filter on Breath Profiles Measured by Secondary Electrospray High-Resolution Mass Spectrometry

Environmental volatile organic compounds (VOCs) from the ambient air potentially influence on-line breath analysis measurements by secondary electrospray ionization high-resolution mass spectrometry (SESI-HRMS). The aim of this study was to investigate how inhaling through a VOC filter affects the detected breath profiles and whether it is feasible to integrate such filters into routine measurements. A total of 24 adult participants performed paired breath analysis measurements with and without the use of an activated carbon filter for inspiration. Concordance correlation coefficients (CCCs) and the Bland−Altman analysis were used to assess the agreement between the two methods. Additionally, the effect on a selection of known metabolites and contaminants was analyzed. Out of all the detected features, 78.3% showed at least a moderate agreement before and after filter usage (CCC > 0.9). The decrease in agreement of the remaining m/z features was mostly associated with reduced signal intensities after filter usage. Although a moderate-to-substantial concordance was found for almost 80% of the m/z features, the filter still had an effect by decreasing signal intensities, not only for contaminants, but also for some of the studied metabolites. Operationally, the use of the filter complicated and slowed down the conductance of measurements, limiting its applicability in clinical studies.

Breathomics profiling of metabolic pathways affected by major depression: Possibilities and limitations

BACKGROUND

Major depressive disorder (MDD) is one of the most common psychiatric disorders with multifactorial etiologies. Metabolomics has recently emerged as a particularly potential quantitative tool that provides a multi-parametric signature specific to several mechanisms underlying the heterogeneous pathophysiology of MDD. The main purpose of the present study was to investigate possibilities and limitations of breath-based metabolomics, breathomics patterns to discriminate MDD patients from healthy controls (HCs) and identify the altered metabolic pathways in MDD.

METHODS

Breath samples were collected in Tedlar bags at awakening, 30 and 60 min after awakening from 26 patients with MDD and 25 HCs. The non-targeted breathomics analysis was carried out by proton transfer reaction mass spectrometry. The univariate analysis was first performed by T-test to rank potential biomarkers. The metabolomic pathway analysis and hierarchical clustering analysis (HCA) were performed to group the significant metabolites involved in the same metabolic pathways or networks. Moreover, a support vector machine (SVM) predictive model was built to identify the potential metabolites in the altered pathways and clusters. The accuracy of the SVM model was evaluated by receiver operating characteristics (ROC) analysis.

RESULTS

A total of 23 differential exhaled breath metabolites were significantly altered in patients with MDD compared with HCs and mapped in five significant metabolic pathways including aminoacyl-tRNA biosynthesis (p = 0.0055), branched chain amino acids valine, leucine and isoleucine biosynthesis (p = 0.0060), glycolysis and gluconeogenesis (p = 0.0067), nicotinate and nicotinamide metabolism (p = 0.0213) and pyruvate metabolism (p = 0.0440). Moreover, the SVM predictive model showed that butylamine (p = 0.0005, p_FDR=0.0006), 3-methylpyridine (p = 0.0002, p_FDR = 0.0012), endogenous aliphatic ethanol isotope (p = 0.0073, p_FDR = 0.0174), valeric acid (p = 0.005, p_FDR = 0.0162) and isoprene (p = 0.038, p_FDR = 0.045) were potential metabolites within identified clusters with HCA and altered pathways, and discriminated between patients with MDD and non-depressed ones with high sensitivity (0.88), specificity (0.96) and area under curve of ROC (0.96).

CONCLUSION

According to the results of this study, the non-targeted breathomics analysis with high-throughput sensitive analytical technologies coupled to advanced computational tools approaches offer completely new insights into peripheral biochemical changes in MDD.

Mass spectrometry based high-throughput bioanalysis of low molecular weight compounds: are we ready to support personalized medicine?

Liquid chromatography coupled to mass spectrometry (LC-MS) is the gold standard in bioanalysis for the development of quantitative assays to support drug development or therapeutic drug monitoring. High-throughput and low-cost gene sequencing have enabled a paradigm shift from one treatment fits all to personalized medicine (PM). However, gene monitoring provides only partial information about the health state. The full picture requires the combination of gene monitoring with the screening of exogenous compounds, metabolites, lipids, and proteins. This critical review discusses how mass spectrometry–based technologies and approaches including separation sciences, ambient ionization, and ion mobility are/could be used to support high-throughput bioanalysis of endogenous end exogenous low molecular weight compounds. It includes also various biological sample types (from blood to expired air), and various sample preparation techniques.

Rapid and sensitive detection of acetone in exhaled breath through the ambient reaction with water radical cations

The levels of acetone and other ketones in exhaled human breath can be associated with various metabolic conditions, e.g. ketosis, lung cancer, dietary fat loss and diabetes. In this study, ketones in breath samples were charged through the reaction with water radical cations to form [M + H₂O]˙⁺ ions, which were detected by mass spectrometry. Our experimental data indicate that under the optimized experimental conditions, the limit of detection for acetone using our approach is 0.14 ng L^-1 (∼0.06 ppb). The linear dynamic range of detection spans four orders of magnitude. The developed approach was applied to real-time semi-quantitative analysis of acetone in the exhaled breath of human volunteers, revealing significantly higher levels of acetone in the breath of smokers compared to non-smokers. The developed approach features the obviation of sample collection, easy operation, high speed of analysis (10 s per run), high sensitivity, and spectral interpretation, which indicates the potential of ambient corona discharge ionization mass spectrometry as a selective, sensitive and noninvasive technique for the determination of exhaled ketones in clinical diagnosis including lung cancer, diabetes, etc.

A literature survey of all volatiles from healthy human breath and bodily fluids: the human volatilome

This paper comprises an updated version of the 2014 review which reported 1846 volatile organic compounds (VOCs) identified from healthy humans. In total over 900 additional VOCs have been reported since the 2014 review and the VOCs from semen have been added. The numbers of VOCs found in breath and the other bodily fluids are: blood 379, breath 1488, faeces 443, milk 290, saliva 549, semen 196, skin 623 and urine 444. Compounds were assigned CAS registry numbers and named according to a common convention where possible. The compounds have been included in a single table with the source reference(s) for each VOC, an update on our 2014 paper. VOCs have also been grouped into tables according to their chemical class or functionality to permit easy comparison. Careful use of the database is needed, as a number of the identified VOCs only have level 2-putative assignment, and only a small fraction of the reported VOCs have been validated by standards. Some clear differences are observed, for instance, a lack of esters in urine with a high number in faeces and breath. However, the lack of compounds from matrices such a semen and milk compared to breath for example could be due to the techniques used or reflect the intensity of effort e.g. there are few publications on VOCs from milk and semen compared to a large number for breath. The large number of volatiles reported from skin is partly due to the methodologies used, e.g. by collecting skin sebum (with dissolved VOCs and semi VOCs) onto glass beads or cotton pads and then heating to a high temperature to desorb VOCs. All compounds have been included as reported (unless there was a clear discrepancy between name and chemical structure), but there may be some mistaken assignations arising from the original publications, particularly for isomers. It is the authors' intention that this work will not only be a useful database of VOCs listed in the literature but will stimulate further study of VOCs from healthy individuals; for example more work is required to confirm the identification of these VOCs adhering to the principles outlined in the metabolomics standards initiative. Establishing a list of volatiles emanating from healthy individuals and increased understanding of VOC metabolic pathways is an important step for differentiating between diseases using VOCs.

Sub-nanoliter metabolomics via mass spectrometry to characterize volume-limited samples

The human metabolome provides a window into the mechanisms and biomarkers of various diseases. However, because of limited availability, many sample types are still difficult to study by metabolomic analyses. Here, we present a mass spectrometry (MS)-based metabolomics strategy that only consumes sub-nanoliter sample volumes. The approach consists of combining a customized metabolomics workflow with a pulsed MS ion generation method, known as triboelectric nanogenerator inductive nanoelectrospray ionization (TENGi nanoESI) MS. Samples tested with this approach include exhaled breath condensate collected from cystic fibrosis patients as well as in vitro-cultured human mesenchymal stromal cells. Both test samples are only available in minimum amounts. Experiments show that picoliter-volume spray pulses suffice to generate high-quality spectral fingerprints, which increase the information density produced per unit sample volume. This TENGi nanoESI strategy has the potential to fill in the gap in metabolomics where liquid chromatography-MS-based analyses cannot be applied. Our method opens up avenues for future investigations into understanding metabolic changes caused by diseases or external stimuli.

Detection of Volatile Organic Compounds with Secondary Electrospray Ionization and Proton Transfer Reaction High-Resolution Mass Spectrometry: A Feature Comparison

The analysis of volatiles is of high relevance for a wide range of applications from environmental air sampling and security screening to potential medical applications. High-resolution mass spectrometry methods offer a particularly wide compound coverage, sensitivity, and selectivity. Online approaches allow direct analysis in real time without the need for sample preparation. For the first time, we systematically compared the analysis of volatile organic compounds with secondary electrospray ionization (SESI) and proton transfer reaction (PTR) high-resolution mass spectrometry. The selected instruments had comparable mass resolving powers with m/Δm ≥ 15000, which is particularly suitable for nontargeted analysis, for example, of exhaled breath. Exhalations from 14 healthy adults were analyzed simultaneously on both instruments. In addition, 97 reference standards from nine chemical classes were analyzed with a liquid evaporation system. Surprisingly, in breath, we found more complementary than overlapping features. A clear mass dependence was observed for each method with the highest number of detected m/z features for SESI in the high mass region (m/z = 150-250) and for PTR in the low mass region (m/z = 50-150). SESI yielded a significantly higher numbers of peaks (828) compared to PTR (491) among a total of 1304 unique breath m/z features. The number of signals observed by both methods was lower than expected (133 features) with 797 unique SESI features and 374 unique PTR features. Hypotheses to explain the observed mass-dependent differences are proposed.

Exploiting the native inspiratory ability of a mass spectrometer to improve analysis efficiency

In this study, a new approach to perform self-aspirating sampling in mass spectrometry (MS) analysis was developed by using the native inspiratory ability of a mass spectrometer. Specifically, the inspiratory channel and sampling inlet of the MS instrument were integrated into a single pathway through a sealed ionization chamber to facilitate analyte delivery and improve sample utilization. Based on this approach, combined with structural simplification and optimization, a versatile electrospray ionization (ESI) source has been constructed and characterized using different mass spectrometers. In addition to the self-aspirating ability, this source configuration can provide sub-ambient pressure (SAP) conditions for ionization, which were conducive to suppressing the background ions generated from some air-involved reactions. Moreover, it can also be used directly for electrospray-driven extraction ionization. With the SAP-ESI source, a conventional mass spectrometer enables rapid analysis of both volatiles and solutions via secondary electrospray ionization and coaxial electrospray ionization, respectively. As the compact gas pathway of the source will promote the efficient transfer and ionization of the sampled substances, the total consumption of the analyte for each analysis can be reduced to subnanogram level and a subppbv limit detection is achieved. Other demonstrated features such as the versatility, easy operation as well as simple assembly will likely contribute to the prevalence of the proposed sampling and ionization strategy.

In this study, a new approach to perform self-aspirating sampling in mass spectrometry (MS) analysis was developed by using the native inspiratory ability of a mass spectrometer.

On-Line Analysis of Exhaled Breath Focus Review

On-line analysis of exhaled breath offers insight into a person's metabolism without the need for sample preparation or sample collection. Due to its noninvasive nature and the possibility to sample continuously, the analysis of breath has great clinical potential. The unique features of this technology make it an attractive candidate for applications in medicine, beyond the task of diagnosis. We review the current methodologies for on-line breath analysis, discuss current and future applications, and critically evaluate challenges and pitfalls such as the need for standardization. Special emphasis is given to the use of the technology in diagnosing respiratory diseases, potential niche applications, and the promise of breath analysis for personalized medicine. The analytical methodologies used range from very small and low-cost chemical sensors, which are ideal for continuous monitoring of disease status, to optical spectroscopy and state-of-the-art, high-resolution mass spectrometry. The latter can be utilized for untargeted analysis of exhaled breath, with the capability to identify hitherto unknown molecules. The interpretation of the resulting big data sets is complex and often constrained due to a limited number of participants. Even larger data sets will be needed for assessing reproducibility and for validation of biomarker candidates. In addition, molecular structures and quantification of compounds are generally not easily available from on-line measurements and require complementary measurements, for example, a separation method coupled to mass spectrometry. Furthermore, a lack of standardization still hampers the application of the technique to screen larger cohorts of patients. This review summarizes the present status and continuous improvements of the principal on-line breath analysis methods and evaluates obstacles for their wider application.

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

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

Molecular breath analysis supports altered amino acid metabolism in idiopathic pulmonary fibrosis

BACKGROUND AND OBJECTIVE

Diagnosis of idiopathic pulmonary fibrosis (IPF) is complex and its pathogenesis is poorly understood. Recent findings indicate elevated levels of proline and other amino acids in lung tissue of IPF patients which may also be of diagnostic value. Following these findings, we hypothesized that such altered metabolic profiles would be mirrored in exhaled breath and could therefore be captured non-invasively in real time.

METHODS

We aimed to validate these results using real-time exhaled breath analysis by secondary electrospray ionization-mass spectrometry, which can provide a non-invasive, painless and fast insight into the metabolism. Breath analysis was performed in a matched 1:1 case-control study involving 21 patients with IPF and 21 control subjects.

RESULTS

We found significantly (P < 0.05) elevated levels of proline, 4-hydroxyproline, alanine, valine, leucine/isoleucine and allysine in breath of IPF patients, whereas pyroglutamic acid and phenylalanine did not show significant differences. This coincides with the amino acid's abundance in pulmonary tissue indicating that our observations reflect progressing fibrosis. In addition, amino acid levels correlated across subjects, further supporting a common underlying pathway. We were able to obtain a cross-validated area under the curve of 0.86, suggesting that these increased amino acid levels in exhaled breath have the potential to be used as biomarkers for IPF.

CONCLUSION

We could validate previous findings of elevated lung tissue amino acid levels in IPF and show that online breath analysis might be a practical tool for a rapid screening for IPF.

Non-separative mass spectrometry methods for non-invasive medical diagnostics based on volatile organic compounds: A review

In this review, an assessment of non-separative methods based on mass spectrometry used to analyse volatile organic compounds in the field of bioanalysis is performed. The use of non-separative methods based on mass spectrometry has been established as an attractive option for analysing compounds. These instrumental configurations are suitable for biomedical applications because of their versatility, rapid output of results, and the wide range of volatile organic compounds that can be determined. Here, techniques such as headspace sampling coupled to mass spectrometry, membrane introduction mass spectrometry, selected ion flow tube mass spectrometry, proton transfer reaction mass spectrometry, secondary electrospray ionization mass spectrometry and ion mobility mass spectrometry, are evaluated. Samples involving non-invasive methods of collection, such as urine, saliva, breath and sweat, are mainly considered. To the best of our knowledge, a comprehensive review of all the non-separative instrumental configurations applied to the analysis of gaseous samples from all matrices non-invasively collected has not yet been carried out. The assessment of non-separative techniques for the analysis of these type of samples can be considered a key issue for future clinical applications, as they allow real-time sample analysis, without patient suffering. Any contribution to the early diagnosis of disease can be considered a priority for the scientific community. Therefore, the identification and determination of volatile organic compounds related to particular diseases has become an important field or research.

Real-time Breath Analysis by Using Secondary Nanoelectrospray Ionization Coupled to High Resolution Mass Spectrometry

Exhaled volatile organic compounds (VOCs) have aroused considerable interest, since they can serve as biomarkers for disease diagnosis and environmental exposure in a non-invasive manner. In this work, we present a protocol to characterize the exhaled VOCs in real time by using secondary nanoelectrospray ionization coupled to high resolution mass spectrometry (Sec-nanoESI-HRMS). The homemade Sec-nanoESI source was readily set up based on a commercial nanoESI source. Hundreds of peaks were observed in the background-subtracted mass spectra of exhaled breath, and the mass accuracy values are -4.0-13.5 ppm and -20.3-1.3 ppm in the positive and negative ion detection modes, respectively. The peaks were assigned with accurate elemental composition according to the accurate mass and isotopic pattern. Less than 30 s is used for one exhalation measurement, and it takes approximately 7 min for six replicated measurements.

Investigation on the influence of time-of-day on benzene metabolic pharmacokinetics by direct breath analysis in mice

Benzene, well known as a ubiquitous environmental pollutant, can lead to increasing risk of cancer, bone marrow failure as well as other serious diseases. Benzene has been classified as carcinogenic to humans with no recommended safe level of exposure. In this study, the influence of time-of-day on benzene metabolism has been tentatively explored in a mouse model based on direct real-time breath analysis by using membrane inlet single photon ionization time of flight mass spectrometry (MI-SPI-TOFMS). The exhaled breath of eight mice was monitored at a time resolution of less than 20 s after intraperitoneal (I.P.) injection of benzene in the morning, afternoon and evening on different days, and two rounds of experiments were carried out in total. The pharmacokinetic parameters such as total exposure AUC_0-∞ (h ng/mL), peak level C_max (ng/mL), time of peak level t_max (h), and terminal half-life t_1/2z (h) were calculated and discussed. The values of individual parameter varied greatly among the eight mice, e.g., AUC_0-∞ in the morning of the first round of experiment ranged from 10.66 to 162.17 h ng/mL and the mean ± SD was 103.72 ± 99.72 h ng/mL (n = 8). Significant difference has also been observed between two rounds of experiments, implying the damage in the liver caused by the benzene exposure. However, there is no significant difference among the results from the morning, afternoon and evening for each round of the experiment. In our follow-up study, the influence of time-of-day will be further investigated, in which the metabolites of benzene as well as endogenous metabolites will be considered.