Methods of NO detection in exhaled breath

Simultaneous real-time detection of fractional exhaled nitric oxide and end-tidal carbon dioxide by quantum cascade laser absorption spectroscopy

The simultaneous detection of fractional exhaled nitric oxide (FeNO) and end-tidal carbon dioxide (ETCO2) is of great importance for the distinguishing and diagnosis of asthma and chronic obstructive pulmonary disease (COPD), providing more comprehensive information on respiratory disorders. This work demonstrates a simultaneous ETCO2 and FeNO detection system based on quantum cascade laser absorption spectroscopy (QCLAS) technology was presented. The system employs wavelength modulation spectroscopy (WMS) technology and the Herriott multi-pass cell, achieving a detection limit of 2.82 ppb for nitric oxide (NO) and 0.05 % for carbon dioxide (CO2). Real-time exhalation measurements were performed on volunteers with varying ETCO2 and FeNO levels, and the results of the test can accurately distinguish whether the corresponding volunteer was healthy, had asthma or COPD. The effect of exhalation flow rate on the concentration of the two gases was explored. A range of expiratory flow rates were tested in the flow rate interval from 1 to 4 L/min, and there was always an inverse relationship between expiratory flow rate and FeNO concentration, but flow rate changes did not affect ETCO2 concentration. The results indicate that this detection system can simultaneously and effectively measure ETCO2 and FeNO concentrations in real-time.

Combining nitric oxide and calcium sensing for the detection of endothelial dysfunction

Cardiovascular diseases are the leading cause of death worldwide and are not typically diagnosed until the disease has manifested. Endothelial dysfunction is an early, reversible precursor in the irreversible development of cardiovascular diseases and is characterized by a decrease in nitric oxide production. We believe that more reliable and reproducible methods are necessary for the detection of endothelial dysfunction. Both nitric oxide and calcium play important roles in the endothelial function. Here we review different types of molecular sensors used in biological settings. Next, we review the current nitric oxide and calcium sensors available. Finally, we review methods for using both sensors for the detection of endothelial dysfunction.

NOx Sensor Constructed from Conductive Metal-Organic Framework and Graphene for Airway Inflammation Screening

The detection of nitric oxide in human exhaled breath (EB) has received wide attention due to its close relationship with respiratory tract inflammation. Herein, a ppb-level NOx chemiresistive sensor was prepared by assembling graphene oxide (GO) with a conductive π-d conjugated metal-organic framework Co3(HITP)2 (HITP = 2,3,6,7,10,11-hexaiminotriphenylene) in the presence of poly(dimethyldiallylammonium chloride) (PDDA). The construction of a gas sensor chip was achieved by drop-casting the GO/PDDA/Co3(HITP)2 composite onto ITO-PET interdigital electrodes, followed by in situ reduction of GO to reduced graphene oxide (rGO) in hydrazine hydrate vapor. Compared with bare rGO, the nanocomposite shows significantly improved sensitivity and selectivity for NOx among various gas analytes owing to its folded and porous structure as well as its numerous active sites. The limit of detection (LOD) for NO and NO2 can reach as low as 11.2 and 6.8 ppb, respectively, and the response/recovery time to 200 ppb NO is 24/41 s. These results indicate that rGO/PDDA/Co3(HITP)2 can achieve a sensitive and fast response toward NOx at room temperature (RT). Additionally, good repeatability and long-term stability were observed. Furthermore, the sensor shows improved humidity tolerance owing to the presence of hydrophobic benzene rings in Co3(HITP)2. To demonstrate its ability in EB detection, EB samples collected from healthy individuals were spiked with a certain amount of NO to simulate the EB of respiratory inflammatory patients. The sensor can successfully distinguish healthy people from the simulated patients. Furthermore, in real clinical sample detection, the sensor can further differentiate acute respiratory inflammatory patients from the chronic ones.

Metal-Multilayered Nanomechanical Cantilever Sensor for Detection of Molecular Adsorption

A metal-multilayered nanomechanical cantilever sensor was proposed to reduce the temperature effect for highly sensitive gas molecular detection. The multilayer structure of the sensor reduces the bimetallic effect, allowing for the detection of differences in molecular adsorption properties on various metal surfaces with higher sensitivity. Our results indicate that the sensor exhibits higher sensitivity to molecules with greater polarity under mixed conditions with nitrogen gas. We demonstrate that stress changes caused by differences in molecular adsorption on different metal surfaces can be detected and that this approach could be used to develop a gas sensor with selectivity for specific gas species.

Nasal Nitric Oxide as a Biomarker in the Diagnosis and Treatment of Sinonasal Inflammatory Diseases: A Review of the Literature

OBJECTIVE

To critically review the literature on nasal nitric oxide (nNO) and its current clinical and research applicability in the diagnosis and treatment of different sinonasal inflammatory diseases, including acute bacterial rhinosinusitis (ABRS), allergic rhinitis (AR), and chronic rhinosinusitis (CRS).

METHODS

A search of the PubMed database was conducted to include articles on nNO and sinonasal diseases from January 2003 to January 2020. All article titles and abstracts were reviewed to assess their relevance to nNO and ABRS, AR, or CRS. After selection of the manuscripts, full-text reviews were performed to synthesize current understandings of nNO and its applications to the various sinonasal inflammatory diseases.

RESULTS

A total of 79 relevant studies from an initial 559 articles were identified using our focused search and review criteria. nNO has been consistently shown to be decreased in ABRS and CRS, especially in cases with nasal polyps. While AR is associated with elevations in nNO, nNO levels have also been found to be lower in AR cases with higher symptom severity. The obstruction of the paranasal sinuses is speculated to be an important variable in the relationship between nNO and the sinonasal diseases. Treatment of these diseases appears to affect nNO through the reduction of inflammatory disease burden and also mitigation of sinus obstruction.

CONCLUSION

nNO has been of increasing interest to researchers and clinicians over the last decade. The most compelling data for nNO as a clinical tool involve CRS. nNO can be used as a marker of ostiomeatal complex patency. Variations in measurement techniques and technology continue to impede standardized interpretation and implementation of nNO as a biomarker for sinonasal inflammatory diseases.

Exhaled Biomarkers for Point-of-Care Diagnosis: Recent Advances and New Challenges in Breathomics

Cancers, chronic diseases and respiratory infections are major causes of mortality and present diagnostic and therapeutic challenges for health care. There is an unmet medical need for non-invasive, easy-to-use biomarkers for the early diagnosis, phenotyping, predicting and monitoring of the therapeutic responses of these disorders. Exhaled breath sampling is an attractive choice that has gained attention in recent years. Exhaled nitric oxide measurement used as a predictive biomarker of the response to anti-eosinophil therapy in severe asthma has paved the way for other exhaled breath biomarkers. Advances in laser and nanosensor technologies and spectrometry together with widespread use of algorithms and artificial intelligence have facilitated research on volatile organic compounds and artificial olfaction systems to develop new exhaled biomarkers. We aim to provide an overview of the recent advances in and challenges of exhaled biomarker measurements with an emphasis on the applicability of their measurement as a non-invasive, point-of-care diagnostic and monitoring tool.

Measurement of nitric oxide spectral parameters: Considering the effects of CO2 and H2O

A continuous-wave quantum cascade laser (CW-QCL) based spectrometer is developed to investigate the high-resolution spectral parameters of nitric oxide (NO). Line strengths and nitrogen (N₂)-, carbon dioxide (CO₂)-, water vapor (H₂O)-, broadening coefficients for NO R(6.5) are measured. The spectral region ranging from 1989 cm^-1 to 1901 cm^-1, which is suitable for the in situ laser sensing of trace NO, is investigated. Spectral parameters are determined by fitting absorption spectra with multi-peak Voigt profiles. The measured intensities are compared to the HITRAN2020 database to assess the performance of the system and a good agreement within ±5% is obtained for the established lines. The measurement results are useful for the design of a spectroscopic sensor for monitoring exhaled breath NO, vehicle exhaust, and industrial emissions.

Millimeter-wave gas spectroscopy for breath analysis of COPD patients in comparison to GC-MS

The analysis of human breath is a very active area of research, driven by the vision of a fast, easy, and non-invasive tool for medical diagnoses at the point of care. Millimeter-wave gas spectroscopy (MMWGS) is a novel, well-suited technique for this application as it provides high sensitivity, specificity and selectivity. Most of all, it offers the perspective of compact low-cost systems to be used in doctors' offices or hospitals. In this work, we demonstrate the analysis of breath samples acquired in a medical environment using MMWGS and evaluate validity, reliability, as well as limitations and perspectives of the method. To this end, we investigated 28 duplicate samples from chronic obstructive lung disease patients and compared the results to gas chromatography-mass spectrometry (GC-MS). The quantification of the data was conducted using a calibration-free fit model, which describes the data precisely and delivers absolute quantities. For ethanol, acetone, and acetonitrile, the results agree well with the GC-MS measurements and are as reliable as GC-MS. The duplicate samples deviate from the mean values by only 6% to 18%. Detection limits of MMWGS depend strongly on the molecular species. For example, acetonitrile can be traced down to 1.8 × 10^-12mol by the MMWGS system, which is comparable to the GC-MS system. We observed correlations of abundances between formaldehyde and acetaldehyde as well as between acetonitrile and acetaldehyde, which demonstrates the potential of MMWGS for breath research.

Liquid Metal-Based Epidermal Flexible Sensor for Wireless Breath Monitoring and Diagnosis Enabled by Highly Sensitive SnS2 Nanosheets

Real-time wireless respiratory monitoring and biomarker analysis provide an attractive vision for noninvasive telemedicine such as the timely prevention of respiratory arrest or for early diagnoses of chronic diseases. Lightweight, wearable respiratory sensors are in high demand as they meet the requirement of portability in digital healthcare management. Meanwhile, high-performance sensing material plays a crucial role for the precise sensing of specific markers in exhaled air, which represents a complex and rather humid environment. Here, we present a liquid metal-based flexible electrode coupled with SnS2 nanomaterials as a wearable gas-sensing device, with added Bluetooth capabilities for remote respiratory monitoring and diagnoses. The flexible epidermal device exhibits superior skin compatibility and high responsiveness (1092%/ppm), ultralow detection limits (1.32 ppb), and a good selectivity of NO gas at ppb-level concentrations. Taking advantage of the fast recovery kinetics of SnS2 responding to H2O molecules, it is possible to accurately distinguish between different respiratory patterns based on the amount of water vapor in the exhaled air. Furthermore, based on the different redox types of H2O and NO molecules, the electric signal is reversed once the exhaled NO concentration exceeds a certain threshold that may indicate the onset of conditions like asthma, thus providing an early warning system for potential lung diseases. Finally, by integrating the wearable device into a wireless cloud-based multichannel interface, we provide a proof-of-concept that our device could be used for the simultaneous remote monitoring of several patients with respiratory diseases, a crucial field in future digital healthcare management.

Measurement of Exhaled Nitric Oxide in 456 Lung Cancer Patients Using a Ringdown FENO Analyzer

The objective of this study was to investigate the clinical value of exhaled nitric oxide (NO) for diagnosing lung cancer patients by using a relatively large sample. An online and near-real-time ringdown exhaled NO analyzer calibrated by an electrochemical sensor at clinical was used for breath analysis. A total of 740 breath samples from 284 healthy control subjects (H) and 456 lung cancer patients (LC) were collected. The recorded data included exhaled NO, medications taken within the last half month, demographics, fasting status and smoking status. The LC had a significantly higher level of exhaled NO than the H (H: 21.0 ± 12.1 ppb vs. LC: 34.1 ± 17.2 ppb). The area under the receiver operating characteristic curve for exhaled NO predicting LC and H was 0.728 (sensitivity was 0.798; specificity was 0.55). There was no significant difference in exhaled NO level between groups divided by different types of LC, tumor node metastasis (TNM) stage, sex, smoking status, age, body mass index (BMI) or fasting status. Exhaled NO level alone is not a useful clinical tool for identifying lung cancer, but it should be considered when developing a diagnosis model of lung cancer by using breath analysis.

Monitoring of endogenous nitric oxide exhaled by pig lungs during ex-vivo lung perfusion

In the context of organ shortage for transplantation, new criteria for better organ evaluation should be investigated. Ex-Vivo Lung Perfusion (EVLP) allows extra-corporal lung re-conditioning and evaluation, under controlled parameters of the organ reperfusion and mechanical ventilation. This work reports on the interest of exhaled gas analysis during the EVLP procedure. After a one-hour cold ischemia, the endogenous gas production by an isolated lung of nitric oxide and carbon monoxide is simultaneously monitored in real time. The exhaled gas is analysed with two very sensitive and selective laser spectrometers developed upon the technique of optical-feedback cavity-enhanced absorption spectroscopy. Exhaled gas concentration measured for an ex-vivo lung is compared to the corresponding production by the whole living pig, measured before euthanasia. On-line measurements of the fraction of nitric oxide in exhaled gas (FENO) in isolated lungs are reported here for the first time, allowing to resolve the respiratory cycles. In this study, performed on 9 animals, FENO by isolated lungs range from 3.3 to 10.6 ppb with a median value of 4.4 ppb. Pairing ex-vivo lung and pig measurements allows to demonstrate a systematic increase of FENO in the ex-vivo lung as compared to the living animal, by a factor of 3 ± 1.2. Measurements of the fraction of carbon monoxide in exhaled gas (FECO) confirm levels recorded during previous studies driven to evaluate FECO as a potential marker of ischemia reperfusion injuries. FECO production by ex-vivo lungs ranges from 0.31 to 2.3 ppm with a median value of 0.8 ppm. As expected, these FECO values are lower than the production by the corresponding whole pig body, by a factor of 6.9 ± 2.7.

The comparision of two exhaled nitric oxide analyzers: NIOX VERO and SUNVOU-CA2122

BACKGROUND

As a marker of eosinophilic airway inflammation, fractional exhaled nitric oxide (FeNO) was widely used in clinical practice. NIOX VERO (VERO) and SUNVOU-CA2122 (CA2122) are two commonly used exhaled nitric oxide (eNO) analyzers in China. However, what's the difference and agreement between the two devices and whether the two types of devices can be replaced by each other in the application of common respiratory diseases have not been reported.

OBJECTIVES

The purpose of this study was to compare the two types of devices and to evaluate the difference between them in clinical use and whether they could be replaced.

METHODS

FeNO levels in 244 respiratory patients (including asthma, COPD, chronic cough) were measured by SUNVOU-CA2122 analyzer (CA2122) and NIOX VERO analyzer (VERO), respectively. FeNO values obtained by the two devices were compared and analyzed for the difference. The success rate, the number of attempts and the total time required for a successful measurement by CA2122 and VERO were compared. The FeNO values measured offline by CA2122 were compared with FeNO values measured online by CA2122 and VERO.

RESULTS

FeNO values obtained by CA2122 were slightly higher than those of VERO [median(range): 29.0(9-271) ppb vs 25.5 (5-263) ppb, P=0.000]. There was a high correlation between FeNO values measured by the two types of devices (r = 0.964, P= 0.000). By comparison, there was a high degree of agreement between the FeNO values measured by two devices, in all patients with different respiratory diseases. FeNO values measured online and offline by CA2122 were highly correlated and there was a high degree of agreement between online and offline methods. The success rate of CA2122 was higher than VERO, and the number of attempts (2.1 vs 2.4) and the total time (110.5±35.7 vs 117.5±48.1 seconds) required for a successful measurement by CA2122 were lower than those of VERO.

CONCLUSIONS

CA2122 and VERO can be replaced by each other, and FeNO values can be converted if necessary. CA2122 has some advantages in success rate, the mean attempts and time required for successful measurement of FeNO.

Recent Advances in Nanomaterial-Enabled Wearable Sensors: Material Synthesis, Sensor Design, and Personal Health Monitoring

Wearable sensors have gained much attention due to their potential in personal health monitoring in a timely, cost-effective, easy-operating, and noninvasive way. In recent studies, nanomaterials have been employed in wearable sensors to improve the sensing performance in view of their excellent properties. Here, focus is mainly on the nanomaterial-enabled wearable sensors and their latest advances in personal health monitoring. Different kinds of nanomaterials used in wearable sensors, such as metal nanoparticles, carbon nanomaterials, metallic nanomaterials, hybrid nanocomposites, and bio-nanomaterials, are reviewed. Then, the progress of nanomaterial-based wearable sensors in personal health monitoring, including the detection of ions and molecules in body fluids and exhaled breath, physiological signals, and emotion parameters, is discussed. Furthermore, the future challenges and opportunities of nanomaterial-enabled wearable sensors are discussed.

Accurate real-time FENO expirograms using complementary optical sensors

The fraction of exhaled nitric oxide (F_ENO) is an important biomarker for the diagnosis and management of asthma and other pulmonary diseases associated with airway inflammation. In this study we report on a novel method for accurate, highly time-resolved, real time detection of F_ENO at the mouth. The experimental arrangement is based on a combination of optical sensors for the determination of the temporal profile of exhaled NO and CO₂ concentrations. Breath CO₂ and exhalation flow are measured at the mouth using diode laser absorption spectroscopy (at 2 μm) and differential pressure sensing, respectively. NO is determined in a sidestream configuration using a quantum cascade laser based, cavity-enhanced absorption cell (at 5.2 μm) which simultaneously measures sidestream CO₂. The at-mouth and sidestream CO₂ measurements are used to enable the deconvolution of the sidestream NO measurement back to the at-mouth location. All measurements have a time resolution of 0.1 s, limited by the requirement of a reasonable limit of detection for the NO measurement, which on this timescale is 4.7 ppb (2 σ). Using this methodology, NO expirograms (F_ENOgrams) were measured and compared for eight healthy volunteers. The F_ENOgrams appear to differ qualitatively between individuals and the hope is that the dynamic information encoded in these F_ENOgrams will provide valuable additional insight into the location of the inflammation in the airways and potentially predict a response to therapy. A validation of the measurements at low-time resolution is provided by checking that results from previous studies that used a two-compartment model of NO production can be reproduced using our technology.

Bio-inspired nano-engineered strip for semiquantitative FeNO analysis

A point-of-care, non-invasive, low-cost and sensitive nano-biodiagnostic is needed in today's age for rapid and accurate self-diagnosis as well as for the management of asthma, which is advantageous for low resource areas where asthma is prevalent. The objective of this research work was to prepare the miniature, nanosponges coated paper strip to detect the asthma using certain biomarkers present in exhaled air. The asthma biomarker, nitric oxide present in exhaled air (FeNO) was chosen, which on reaction with nanosponges of diazotizing agent gave significant color change. The pyromellitic anhydride cross-linked β-cyclodextrin-based nanosponges of sulfanilamide and N-(1-naphthyl) ethylenediamine dihydrochloride were prepared using a polymer condensation method and coated on Whatman filter paper strip (1 × 5 cm2). The thickness of coating was found to be uniform (400 ± 50 μm) which was determined using SEM analysis. The Hue-Saturation-Value scale was used to detect the color change using a smartphone app. We also investigated the performance of a nano-engineered paper strip by comparing this with commercially available, FDA approved FeNO analyzer-NIOX MINO. Our findings demonstrated no significant difference in results obtained using both the techniques. Besides good repeatability, the paper strip showed increasing saturation with NO concentration and the capacity to detect the biomarker down to mean value of 20.33 ppb level. The successful validation and method comparison indicated that a bioinspired strip can provide on-site analysis and daily monitoring for diagnosis and management of asthma.

Laser spectroscopy for breath analysis: towards clinical implementation

Detection and analysis of volatile compounds in exhaled breath represents an attractive tool for monitoring the metabolic status of a patient and disease diagnosis, since it is non-invasive and fast. Numerous studies have already demonstrated the benefit of breath analysis in clinical settings/applications and encouraged multidisciplinary research to reveal new insights regarding the origins, pathways, and pathophysiological roles of breath components. Many breath analysis methods are currently available to help explore these directions, ranging from mass spectrometry to laser-based spectroscopy and sensor arrays. This review presents an update of the current status of optical methods, using near and mid-infrared sources, for clinical breath gas analysis over the last decade and describes recent technological developments and their applications. The review includes: tunable diode laser absorption spectroscopy, cavity ring-down spectroscopy, integrated cavity output spectroscopy, cavity-enhanced absorption spectroscopy, photoacoustic spectroscopy, quartz-enhanced photoacoustic spectroscopy, and optical frequency comb spectroscopy. A SWOT analysis (strengths, weaknesses, opportunities, and threats) is presented that describes the laser-based techniques within the clinical framework of breath research and their appealing features for clinical use.

Bayesian estimation of physiological parameters governing a dynamic two-compartment model of exhaled nitric oxide

The fractional concentration of nitric oxide in exhaled breath (fe_NO) is a biomarker of airway inflammation with applications in clinical asthma management and environmental epidemiology. fe_NO concentration depends on the expiratory flow rate. Standard fe_NO is assessed at 50 mL/sec, but “extended NO analysis” uses fe_NO measured at multiple different flow rates to estimate parameters quantifying proximal and distal sources of NO in the lower respiratory tract. Most approaches to modeling multiple flow fe_NO assume the concentration of NO throughout the airway has achieved a “steady‐state.” In practice, this assumption demands that subjects maintain sustained flow rate exhalations, during which both fe_NO and expiratory flow rate must remain constant, and the fe_NO maneuver is summarized by the average fe_NO concentration and average flow during a small interval. In this work, we drop the steady‐state assumption in the classic two‐compartment model. Instead, we have developed a new parameter estimation approach based on measuring and adjusting for a continuously varying flow rate over the entire fe_NO maneuver. We have developed a Bayesian inference framework for the parameters of the partial differential equation underlying this model. Based on multiple flow fe_NO data from the Southern California Children's Health Study, we use observed and simulated NO concentrations to demonstrate that our approach has reasonable computation time and is consistent with existing steady‐state approaches, while our inferences consistently offer greater precision than current methods.

Effects of growth and aging on the reference values of pulmonary nitric oxide dynamics in healthy subjects

The lung just like all other organs is affected by age. The lung matures by the age of 20 and age-related changes start around middle age, at 40-50 years. Exhaled nitric oxide (F_ENO) has been shown to be age, height and gender dependent. We hypothesize that the nitric oxide (NO) parameters alveolar NO (C_ANO), airway flux (J_awNO), airway diffusing capacity (D_awNO) and airway wall content (C_awNO) will also demonstrate this dependence. Data from healthy subjects were gathered by the current authors from their earlier publications in which healthy individuals were included as control subjects. Healthy subjects (n = 433) ranged in age from 7 to 78 years. Age-stratified reference values of the NO parameters were significantly different. Gender differences were only observed in the 20-49 age group. The results from the multiple regression models in subjects older than 20 years revealed that age, height and gender interaction together explained 6% of variation in F_ENO at 50 ml s^-1 (F_ENO₅₀), 4% in J_awNO, 16% in C_awNO, 8% in D_awNO and 12% in C_ANO. In conclusion, in this study we have generated reference values for NO parameters from an extended NO analysis of healthy subjects. This is important in order to be able to use these parameters in clinical practice.

A European Respiratory Society technical standard: exhaled biomarkers in lung disease

Breath tests cover the fraction of nitric oxide in expired gas (F_eNO), volatile organic compounds (VOCs), variables in exhaled breath condensate (EBC) and other measurements. For EBC and for F_eNO, official recommendations for standardised procedures are more than 10 years old and there is none for exhaled VOCs and particles. The aim of this document is to provide technical standards and recommendations for sample collection and analytic approaches and to highlight future research priorities in the field. For EBC and F_eNO, new developments and advances in technology have been evaluated in the current document. This report is not intended to provide clinical guidance on disease diagnosis and management.Clinicians and researchers with expertise in exhaled biomarkers were invited to participate. Published studies regarding methodology of breath tests were selected, discussed and evaluated in a consensus-based manner by the Task Force members.Recommendations for standardisation of sampling, analysing and reporting of data and suggestions for research to cover gaps in the evidence have been created and summarised.Application of breath biomarker measurement in a standardised manner will provide comparable results, thereby facilitating the potential use of these biomarkers in clinical practice.

Effects of specific allergen immunotherapy on biological markers and clinical parameters in asthmatic children: a controlled-real life study

BACKGROUND

Allergen-specific immunotherapy (AIT) is the only treatment able to change the natural course of allergic diseases. We aimed at investigating the clinical efficacy of SLITOR (Serbian registered vaccine for sublingual allergen specific immunotherapy).

METHODS

7-18 years old children with allergic asthma and rhinitis were enrolled and addressed to the active (AIT plus pharmacological treatment) or control (standard pharmacological treatment only) group. Clinical and medications scores, lung function and exhaled FeNO were measured at baseline and at every follow-up.

RESULTS

There was a significant improvement in both nasal and asthma symptom scores as well as in medication score in SLIT group. SLIT showed an important influence on lung function and airway inflammation.

CONCLUSIONS

Our data showed that SLITOR was effective not only in terms of patient reported outcomes but an improvement of pulmonary function and decrease of lower airway inflammation were also observed.

The measurement of DLNO and DLCO: A manufacturer's perspective

The simultaneous measurement of the lung transfer factor for carbon monoxide (DLCO) and nitric oxide (DLNO) is now available as a powerful method for studying the alveolar-capillary gas exchange. However, application of the DLNO-CO technique in daily settings is still limited by some technical drawbacks. This paper provides a manufacturer's overview of the measuring principles, technical challenges and current available solutions for implementing the DLNO-CO measurement in to a marketed device. This includes the recent developments in technology for NO sensors, latest findings on NO uptake and new statistical methods.

Fractional exhaled nitric oxide-measuring devices: technology update

The measurement of exhaled nitric oxide (NO) has been employed in the diagnosis of specific types of airway inflammation, guiding treatment monitoring by predicting and assessing response to anti-inflammatory therapy and monitoring for compliance and detecting relapse. Various techniques are currently used to analyze exhaled NO concentrations under a range of conditions for both health and disease. These include chemiluminescence and electrochemical sensor devices. The cost effectiveness and ability to achieve adequate flexibility in sensitivity and selectivity of NO measurement for these methods are evaluated alongside the potential for use of laser-based technology. This review explores the technologies involved in the measurement of exhaled NO.

Online Measurement of Exhaled NO Concentration and Its Production Sites by Fast Non-equilibrium Dilution Ion Mobility Spectrometry

Exhaled nitric oxide (NO) is one of the most promising breath markers for respiratory diseases. Its profile for exhalation and the respiratory NO production sites can provide useful information for medical disease diagnosis and therapeutic procedures. However, the high-level moisture in exhaled gas always leads to the poor selectivity and sensitivity for ion spectrometric techniques. Herein, a method based on fast non-equilibrium dilution ion mobility spectrometry (NED-IMS) was firstly proposed to directly monitor the exhaled NO profile on line. The moisture interference was eliminated by turbulently diluting the original moisture to 21% of the original with the drift gas and dilution gas. Weak enhancement was observed for humid NO response and its limit of detection at 100% relative humidity was down to 0.58 ppb. The NO concentrations at multiple exhalation flow rates were measured, while its respiratory production sites were determined by using two-compartment model (2CM) and Högman and Meriläinen algorithm (HMA). Last but not the least, the NO production sites were analyzed hourly to tentatively investigate the daily physiological process of NO. The results demonstrated the capacity of NED-IMS in the real-time analysis of exhaled NO and its production sites for clinical diagnosis and assessment.

Traffic-related air pollution and alveolar nitric oxide in southern California children

Mechanisms for the adverse respiratory effects of traffic-related air pollution (TRAP) have yet to be established. We evaluated the acute effects of TRAP exposure on proximal and distal airway inflammation by relating indoor nitric oxide (NO), a marker of TRAP exposure in the indoor microenvironment, to airway and alveolar sources of exhaled nitric oxide (FeNO).FeNO was collected online at four flow rates in 1635 schoolchildren (aged 12-15 years) in southern California (USA) breathing NO-free air. Indoor NO was sampled hourly and linearly interpolated to the time of the FeNO test. Estimated parameters quantifying airway wall diffusivity (DawNO) and flux (J'awNO) and alveolar concentration (CANO) sources of FeNO were related to exposure using linear regression to adjust for potential confounders.We found that TRAP exposure indoors was associated with elevated alveolar NO. A 10 ppb higher indoor NO concentration at the time of the FeNO test was associated with 0.10 ppb higher average CANO (95% CI 0.04-0.16) (equivalent to a 7.1% increase from the mean), 4.0% higher J'awNO (95% CI -2.8-11.3) and 0.2% lower DawNO (95% CI -4.8-4.6).These findings are consistent with an airway response to TRAP exposure that was most marked in the distal airways.

Exhaled NO: Determinants and Clinical Application in Children With Allergic Airway Disease

Nitric oxide (NO) is endogenously released in the airways, and the fractional concentration of NO in exhaled breath (FeNO) is now recognized as a surrogate marker of eosinophilic airway inflammation that can be measured using a noninvasive technique suitable for young children. Although FeNO levels are affected by several factors, the most important clinical determinants of increased FeNO levels are atopy, asthma, and allergic rhinitis. In addition, air pollution is an environmental determinant of FeNO that may contribute to the high prevalence of allergic disease. In this review, we discuss the mechanism for airway NO production, methods for measuring FeNO, and determinants of FeNO in children, including host and environmental factors such as air pollution. We also discuss the clinical utility of FeNO in children with asthma and allergic rhinitis and further useful directions using FeNO measurement.

Microextraction techniques in breath biomarker analysis

Breath volatile organic compound analysis may open a non-invasive window onto (patho)physiological and metabolic processes in the body. Breath tests require controlled sampling with respect to different breath phases and on-site and point-of-care applicability. Microextraction techniques such as solid phase microextraction (SPME) or needle-trap microextraction (NTME) meet these requirements. Small sample volumes and fast and controlled sample preparation combine on-site sampling and pre-concentration in one step. Detection limits in the low ppbV range and fast and simple processing facilitate the application of distribution-based SPME for screening and targeted analysis. Exhaustive NTME has shown further advantages such as fast and automated sampling, improved stability and reproducibility with improved detection limits. Combinations of different sorbents and thermal expansion desorption have shown most promising properties when applied to water saturated breath samples. This article addresses major challenges and advantages of microextraction techniques in breath analysis. Important progress, current applications and future trends are discussed.

New miniaturized exhaled nitric oxide sensor based on a high Q/V mid-infrared 1D photonic crystal cavity

A high Q/V mid-infrared 1D photonic crystal cavity in chalcogenide glass AMTIR-1 (Ge₃₃As₁₂Se₅₅) resonating at λ_R=5.26  μm has been proposed as a key element of a sensor able to evaluate the nitric oxide (NO) concentration in the exhaled breath, namely fraction exhaled NO. The cavity design has been carried out through 3D finite-element method simulations. A Q-factor of 1.1×10⁴ and a mode volume V=0.8  (λ/n)³, corresponding to a Q/V ratio of 1.4×10⁴(λ/n)^-3, have been obtained with a resonance transmission coefficient T=15%. A sensitivity of 10 ppb has been calculated with reference to the photothermal physical property of the material. Such a result is lower than the state-of-the-art of NO sensors proposed in literature, where hundreds of parts per trillion-level detection seem to have been achieved, but comparable with the performance obtained by commercial devices. The main advantages of the new device are in terms of footprint (=150  μm²), smaller at least 1 order of magnitude than those in literature, fast response time (only few seconds), and potential low cost. Such properties make possible in a handheld device the sensor integration in a multi-analysis system for detecting the presence of several trace gases, improving prevention, and reducing the duration of drug treatment for asthma and viral infections.

Technologies for Clinical Diagnosis Using Expired Human Breath Analysis

This review elucidates the technologies in the field of exhaled breath analysis. Exhaled breath gas analysis offers an inexpensive, noninvasive and rapid method for detecting a large number of compounds under various conditions for health and disease states. There are various techniques to analyze some exhaled breath gases, including spectrometry, gas chromatography and spectroscopy. This review places emphasis on some of the critical biomarkers present in exhaled human breath, and its related effects. Additionally, various medical monitoring techniques used for breath analysis have been discussed. It also includes the current scenario of breath analysis with nanotechnology-oriented techniques.

Dopant titrating ion mobility spectrometry for trace exhaled nitric oxide detection

Ion mobility spectrometry (IMS) is a promising non-invasive tool for the analysis of exhaled gas and exhaled nitric oxide (NO), a biomarker for diagnosis of respiratory diseases. However, the high moisture in exhaled gas always brings about extra overlapping ion peaks and results in poor identification ability. In this paper, p-benzoquinone (PBQ) was introduced into IMS to eliminate the interference of overlapping ion peaks and realize the selective identification of NO. The overlapping ions caused by moisture were titrated by PBQ and then converted to hydrated PBQ anions (C6H4[Formula: see text](H2O)n). The NO concentration could be determined by quantifying gas phase hydrated nitrite anions (N[Formula: see text](H2O)n), product ions of NO. Under optimized conditions, a limit of detection (LOD) of about 1.4 ppbv and a linear range of 10-200 ppbv were obtained for NO even in 100% relative humidity (RH) purified air. Furthermore, this established method was applied to measure hourly the exhaled NO of eight healthy volunteers, and real-time monitoring the exhaled NO of an esophageal carcinoma patient during radical surgery. These results revealed the potential of the current dopant titrating IMS method in the measurement of exhaled NO for medical disease diagnosis.

Clinical application of exhaled nitric oxide measurements in a korean population

Nitric oxide (NO) is a biologic mediator of various physiologic functions. Recent evidence suggests the clinical utility of fractional exhaled NO (FeNO) as a biomarker for assessing asthma and other respiratory diseases. FeNO methodologies have been recently standardized by international research groups and subsequently validated in several Korean population studies. Normal ranges for FeNO have been reported for various ethnic groups, and the clinical utility has been widely evaluated in asthma and various respiratory diseases. Based on current evidence including most of Korean population data, this position paper aims to introduce the methodological considerations, and provide the guidance for the proper clinical application of FeNO measurements in Korean populations.

Association of wheezing phenotypes with fractional exhaled nitric oxide in children

Asthma comprises a heterogeneous group of disorders characterized by airway inflammation, airway obstruction, and airway hyperresponsiveness (AHR). Airway inflammation, which induces AHR and recurrence of asthma, is the main pathophysiology of asthma. The fractional exhaled nitric oxide (FeNO) level is a noninvasive, reproducible measurement of eosinophilic airway inflammation that is easy to perform in young children. As airway inflammation precedes asthma attacks and airway obstruction, elevated FeNO levels may be useful as predictive markers for risk of recurrence of asthma. This review discusses FeNO measurements among early-childhood wheezing phenotypes that have been identified in large-scale longitudinal studies. These wheezing phenotypes are classified into three to six categories based on the onset and persistence of wheezing from birth to later childhood. Each phenotype has characteristic findings for atopic sensitization, lung function, AHR, or FeNO. For example, in one birth cohort study, children with asthma and persistent wheezing at 7 years had higher FeNO levels at 4 years compared to children without wheezing, which suggested that FeNO could be a predictive marker for later development of asthma. Preschool-aged children with recurrent wheezing and stringent asthma predictive indices also had higher FeNO levels in the first 4 years of life compared to children with wheezing and loose indices or children with no wheeze, suggesting that FeNO measurements may provide an additional parameter for predicting persistent wheezing in preschool children. Additional large-scale longitudinal studies are required to establish cutoff levels for FeNO as a risk factor for persistent asthma.

Assessment of the exhalation kinetics of volatile cancer biomarkers based on their physicochemical properties

The current review provides an assessment of the exhalation kinetics of volatile organic compounds (VOCs) that have been linked with cancer. Towards this end, we evaluate various physicochemical properties, such as 'breath:air' and 'blood:fat' partition coefficients, of 112 VOCs that have been suggested over the past decade as potential markers of cancer. With these data, we show that the cancer VOC concentrations in the blood and in the fat span over 12 and 8 orders of magnitude, respectively, in order to provide a specific counterpart concentration in the exhaled breath (e.g., 1 ppb). This finding suggests that these 112 different compounds have different storage compartments in the body and that their exhalation kinetics depends on one or a combination of the following factors: (i) the VOC concentrations in different parts of the body; (ii) the VOC synthesis and metabolism rates; (iii) the partition coefficients between tissue(s), blood and air; and (iv) the VOCs' diffusion constants. Based on this analysis, we discuss how this knowledge allows modeling and simulating the behavior of a specific VOC under different sampling protocols (with and without exertion of effort). We end this review by a brief discussion on the potential role of these scenarios in screening and therapeutic monitoring of cancer.

A review of the volatiles from the healthy human body

A compendium of all the volatile organic compounds (VOCs) emanating from the human body (the volatolome) is for the first time reported. 1840 VOCs have been assigned from breath (872), saliva (359), blood (154), milk (256), skin secretions (532) urine (279), and faeces (381) in apparently healthy individuals. Compounds were assigned CAS registry numbers and named according to a common convention where possible. The compounds have been grouped into tables according to their chemical class or functionality to permit easy comparison. Some clear differences are observed, for instance, a lack of esters in urine with a high number in faeces. Careful use of the database is needed. The numbers may not be a true reflection of the actual VOCs present from each bodily excretion. The lack of a compound could be due to the techniques used or reflect the intensity of effort e.g. there are few publications on VOCs from blood compared to a large number on VOCs in breath. The large number of volatiles reported from skin is partly due to the methodologies used, e.g. collecting excretions on glass beads and then heating 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 database will not only be a useful database of VOCs listed in the literature, but will stimulate further study of VOCs from healthy individuals. 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.

Applications of absorption spectroscopy using quantum cascade lasers

Infrared laser absorption spectroscopy (LAS) is a promising modern technique for sensing trace gases with high sensitivity, selectivity, and high time resolution. Mid-infrared quantum cascade lasers, operating in a pulsed or continuous wave mode, have potential as spectroscopic sources because of their narrow linewidths, single mode operation, tunability, high output power, reliability, low power consumption, and compactness. This paper reviews some important developments in modern laser absorption spectroscopy based on the use of quantum cascade laser (QCL) sources. Among the various laser spectroscopic methods, this review is focused on selected absorption spectroscopy applications of QCLs, with particular emphasis on molecular spectroscopy, industrial process control, combustion diagnostics, and medical breath analysis.

Factors influencing breath ammonia determination

Amongst volatile compounds (VCs) present in exhaled breath, ammonia has held great promise and yet it has confounded researchers due to its inherent reactivity. Herein we have evaluated various factors in both breath instrumentation and the breath collection process in an effort to reduce variability. We found that the temperature of breath sampler and breath sensor, mouth rinse pH, and mode of breathing to be important factors. The influence of the rinses is heavily dependent upon the pH of the rinse. The basic rinse (pH 8.0) caused a mean increase of the ammonia concentration by 410 ± 221 ppb. The neutral rinse (pH 7.0), slightly acidic rinse (pH 5.8), and acidic rinse (pH 2.5) caused a mean decrease of the ammonia concentration by 498 ± 355 ppb, 527 ± 198 ppb, and 596 ± 385 ppb, respectively. Mode of breathing (mouth-open versus mouth-closed) demonstrated itself to have a large impact on the rate of recovery of breath ammonia after a water rinse. Within 30 min, breath ammonia returned to 98 ± 16% that of the baseline with mouth open breathing, while mouth closed breathing allowed breath ammonia to return to 53 ± 14% of baseline. These results contribute to a growing body of literature that will improve reproducibly in ammonia and other VCs.