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Much effort continues to be devoted to the development of devices to analyse breath ammonia with the anticipation that breath ammonia analyses will be useful in clinical practice. In this perspective we refer to the analytical techniques that have been used to measure breath ammonia, focusing on selected ion flow tube mass spectrometry, SIFT-MS, of which we have special knowledge and understanding. From the collected data obtained using the different techniques, we exam the origins of mouth- and nose-exhaled ammonia and conclude that mouth-exhaled ammonia is always elevated above a concentration that would be equilibrated with blood ammonia and is largely produced by the action of enzymes on salivary urea. Support to this conclusion is given by the reasonable correlation between blood urea concentration and mouth-exhaled ammonia concentration. Further, it is discussed that nose-exhaled ammonia largely originates at the alveolar interface and so its concentration more closely relates to the expected alveolar blood ammonia concentration. Ingestion of proteins results in increased blood/saliva urea and ultimately mouth-exhaled ammonia as does the generation of urease by H. pylori infection. It is also concluded that when mouth-exhaled ammonia is elevated then it may be due to either abnormally high blood urea, a high pH of the saliva/mouth/airways mucosa, poor oral hygiene or a combinations of these.

A study has been carried out on the volatile organic compounds (VOCs) in the exhaled breath of patients suffering from inflammatory bowel disease (IBD), comprising 136 with Crohn's disease (CD) and 51 with ulcerative colitis (UC), together with a cohort of 14 healthy persons as controls. Breath samples were collected by requesting the patients to inflate Nalophan bags, which were then quantitatively analysed using selected ion flow tube mass spectrometry (SIFT-MS). Initially, the focus was on n-pentane that had previously been quantified in single exhalations on-line to SIFT-MS for smaller cohorts of IBD patients. It was seen that the median concentration of pentane was elevated in the bag breath samples of the IBD patients compared to those of the healthy controls, in accordance with the previous study. However, the absolute median pentane concentrations in the bag samples were about a factor of two lower than those in the directly analysed single exhalations-a good illustration of the dilution of VOCs in the samples of breath collected into bags. Accounting for this dilution effect, the concentrations of the common breath VOCs, ethanol, propanol, acetone and isoprene, were largely as expected for healthy controls. The concentrations of the much less frequently measured hydrogen sulphide, acetic acid, propanoic acid and butanoic acid were seen to be more widely spread in the exhaled breath of the IBD patients compared to those for the healthy controls. The relative concentrations of pentane and these other VOCs weakly correlate with simple clinical activity indices. It is speculated that, potentially, hydrogen sulphide and these carboxylic acids could be exhaled breath biomarkers of intestinal bacterial overgrowth, which could assist therapeutic intervention and thus alleviate the symptoms of IBD.

It is argued that shortcomings of certain approaches to breath analysis research based on superficial interpretation of non-quantitative data are inadvertently inhibiting the progression of non-invasive breath analysis into clinical practice. The objective of this perspective is to suggest more clinically profitable approaches to breath research. Thus, following a discourse on the challenges and expectations in breath research, a brief indication is given of the analytical techniques currently used for the analysis of very humid exhaled breath. The seminal work that has been carried out using GC-MS revealed that exhaled breath comprises large numbers of trace volatile organic compounds, VOCs. Unfortunately, analysis of these valuable GC-MS data is mostly performed using chemometrics to distinguish the VOC content of breath samples collected from patients and healthy controls, and reliable quantification of the VOCs is rarely deemed necessary. This limited approach ignores the requirements of clinically acceptable biomarkers and misses the opportunity to identify relationships between the concentrations of individual VOCs and certain related physiological or metabolic parameters. Therefore, a plea is made for more effort to be directed towards the positive identification and accurate quantification of individual VOCs in exhaled breath, which are more physiologically meaningful as best exemplified by the quantification of breath nitric oxide, NO. Support for the value of individual VOC quantification is illustrated by the SIFT-MS studies of breath hydrogen cyanide, HCN, a biomarker of Pseudomonas aeruginosa infection, breath acetic acid as an indicator of airways acidification in cystic fibrosis patients, and n-pentane as a breath biomarker of inflammation in idiopathic bowel disease patients. These single VOCs could be used as non-invasive monitors of the efficacy of therapeutic intervention. The increase of breath methanol following the ingestion of a known amount of the sweetener aspartame impressively shows that accurate breath analysis is a reliable indicator of blood concentrations. However, using individual VOCs for specific disease diagnosis does have its problems and it is, perhaps, more appropriate to see their concentrations as proxy markers of general underlying physiological change. We dedicate this perspective to Lars Gustafsson for his seminal work on breath research and especially for his pioneering work on nitric oxide measurements in exhaled breath in asthma, which best shows the utility and value of the quantification of individual breath biomarkers on which this perspective focuses.

Non-invasive breath analysis has been used to search for volatile biomarkers of lungs and airways infection by Pseudomonas aeruginosa, PA, in cystic fibrosis patients. The exhaled breath of 20 PA-infected patients and 38 PA-negative patients was analysed using selected ion flow tube mass spectrometry, SIFT-MS. Special attention was given to the positive identification and accurate quantification of 16 volatile compounds (VOCs) as assured by the detailed consideration of their analytical ion chemistry occurring in the SIFT-MS reactor. However, the diagnostic sensitivity and specificity of the concentrations of any of the 16 compounds taken individually were found to be low. But when a linear combination of the concentrations of all 16 VOCs was used to construct an optimised receiver operating characteristics (ROC) curve using a linear logistic model, the diagnostic separation of PA-infected patients relative to the PA-negative patients was apparently good in terms of the derived sensitivity (89%), specificity (86%), and the area under the ROC curve is 0.91. Four compounds were revealed by the linear logistic model as significant, viz. malondialdehyde, isoprene, phenol and acetoin. The implications of these results to PA detection in the airways are assessed. Whilst such a metabolomics approach to optimise the ROC curve is widely used in breath analysis, it can lead to misleading indications. Therefore, we conclude that the results of the linear logistic model analyses are of limited immediate clinical value. The identified compounds should rather be considered as a stimulus for further independent studies involving larger patient cohorts.

As a contribution to the continuing search for breath biomarkers of lung and airways infection in patients with cystic fibrosis, CF, we have analysed the volatile metabolites released in vitro by Pseudomonas aeruginosa and other bacteria involved in respiratory infections in these patients, i.e. those belonging to the Burkholderia cepacia complex, Staphylococcus aureus or Stenotrophomonas maltophilia. These opportunistic pathogens are generally harmless to healthy people but they may cause serious infections in patients with severe underlying disease or impaired immunity such as CF patients. Volatile organic compounds emitted from the cultures of strains belonging to the above-mentioned four taxa were analysed by selected ion flow tube mass spectrometry. In order to minimize the effect of differences in media composition all strains were cultured in three different liquid media. Multivariate statistical analysis reveals that the four taxa can be well discriminated by the differences in the headspace VOC concentration profiles. The compounds that should be targeted in breath as potential biomarkers of airway infection were identified for each of these taxa of CF pathogens.

Aspartame, methyl-L-α-aspartyl-L-phenylalaninate, is used worldwide as a sweetener in foods and drinks and is considered to be safe at an acceptable daily intake (ADI) of 40 mg per kg of body weight. This compound is completely hydrolyzed in the gastrointestinal tract to aspartic acid, phenylalanine and methanol, each being toxic at high levels. The objective of the present study was to quantify the volatile methanol component in the exhaled breath of ten healthy volunteers following the ingestion of a single ADI dose of aspartame. Direct on-line measurements of methanol concentration were made in the mouth and nose breath exhalations using selected ion flow tube mass spectrometry, SIFT-MS, several times before aspartame ingestion in order to establish individual pre-dose (baseline) levels and then during two hours post-ingestion to track their initial increase and subsequent decrease. The results show that breath methanol concentrations increased in all volunteers by 1082 ± 205 parts-per-billion by volume (ppbv) from their pre-ingestion values, which ranged from 193 to 436 ppbv to peak values ranging from 981-1622 ppbv, from which they slowly decreased. These observations agree quantitatively with a predicted increase of 1030 ppbv estimated using a one-compartment model of uniform dilution of the methanol generated from a known amount of aspartame throughout the total body water (including blood). In summary, an ADI dose of aspartame leads to a 3-6 fold increase of blood methanol concentration above the individual baseline values.

The aim of the present study was to characterize the volatile metabolites produced by genotypically diverse strains of the Stenotrophomonas genus in order to evaluate their potential as biomarkers of lung infection by non-invasive breath analysis. Volatile organic compounds (VOCs) emitted from 15 clinical and five environmental strains belonging to different genogroups of Stenotrophomonas maltophilia (n = 18) and Stenotrophomonas rhizophila (n = 2) cultured in Mueller-Hinton Broth (MHB) liquid media were analysed by gas chromatography mass spectrometry (GC-MS) and selected ion flow tube mass spectrometry (SIFT-MS). Several VOCs were detected in high concentration, including ammonia, propanol, dimethyl disulphide propanol and dimethyl disulphide. The GC-MS measurements showed that all 15 clinical strains produced similar headspace VOCs compositions, and SIFT-MS quantification showed that the rates of production of the VOCs by the genotypically distinct strains were very similar. All in vitro cultures of both the Stenotrophomonas species were characterised by efficient production of two isomers of methyl butanol, which can be described by known biochemical pathways and which is absent in other pathogens, including Pseudomonas aeruginosa. These in-vitro data indicate that methyl butanol isomers may be exhaled breath biomarkers of S. maltophilia lung infection in patients with cystic fibrosis.

Breath analysis research is being successfully pursued using a variety of analytical methods, prominent amongst which are gas chromatography with mass spectrometry, GC-MS, ion mobility spectrometry, IMS, and the fast flow and flow-drift tube techniques called selected ion flow tube mass spectrometry, SIFT-MS, and proton transfer reaction mass spectrometry, PTR-MS. In this paper the case is made for real-time breath analysis by obviating sample collection into bags or onto traps that can suffer from partial degradation of breath metabolites or the introduction of impurities. Real-time analysis of a broad range of volatile chemical compounds can be best achieved using SIFT-MS and PTR-MS, which are sufficiently sensitive and rapid to allow the simultaneous analyses of several trace gas metabolites in single breath exhalations. The basic principles and the ion chemistry that underpin these two analytical techniques are briefly described and the differences between them, including their respective strengths and weaknesses, are revealed, especially with reference to the analysis of the complex matrix that is exhaled breath. A recent innovation is described that combines time-of-flight mass spectrometry with the proton transfer flow-drift tube reactor, PTR-TOFMS, which provides greater resolution in the analytical mass spectrometer and allows separation of protonated isobaric molecules. Examples are presented of some recent data that well illustrate the quality and real-time feature of SIFT-MS and PTR-MS for the analysis of exhaled breath for physiological/biochemical/pharmacokinetics studies and for the identification and quantification of biomarkers relating to specific disease states.

Since we first recognized the regular presence of gaseous hydrogen cyanide, HCN, in the headspace of plate cultures of the bacterium Pseudomonas aeruginosa, PA, derived from sputum of cystic fibrosis, CF, patients, and following crucial ion chemistry research that allowed accurate quantification of gaseous HCN by selected ion flow tube mass spectrometry, we have carried out many further in vitro and in vivo studies. We have measured HCN in the headspace of various PA culture types, planktonic and biofilm, significant numbers of genetically identified PA strains together with studies of HCN in the mouth-exhaled and nose-exhaled breath of healthy children and adults and those with CF. The major findings are: (i) virtually all strains of PA release HCN when cultured in vitro, as shown by the investigation of more than 150 genetically differentiated strains, both mucoid and non-mucoid. (ii) HCN is present in the mouth-exhaled breath of adults and children, but is at lower concentrations in children. Its concentration is below the detection limit in nose-exhaled breath of healthy people. (iii) HCN is present in both mouth-exhaled and nose-exhaled breath of patients with CF, suggesting the presence of PA in the lower airways as indicated by clinical microbiological cultures. With confirmation of these findings by further research and clinical trials, nose-exhaled breath HCN measurements could be an additional diagnostic tool to detect the early presence of PA in the lower airways and a non-invasive monitor to enhance the likelihood of its eradication.

Throughout the development of breath analysis research, there has been interest in how the concentrations of trace compounds in exhaled breath are related to their concentrations in the ambient inhaled air. In considering this, Phillips introduced the concept of 'alveolar gradient' and judged that the measured exhaled concentrations of volatile organic compounds should be diminished by an amount equal to their concentrations in the inhaled ambient air. The objective of the work described in this paper was to investigate this relationship quantitatively. Thus, experiments have been carried out in which inhaled air was polluted by seven compounds of interest in breath research, as given below, and exhaled breath has been analysed by SIFT-MS as the concentrations of these compounds in the inhaled air were reduced. The interesting result obtained is that all the exogenous compounds are partially retained in the exhaled breath and there are close linear relationships between the exhaled and inhaled air concentrations for all seven compounds. Thus, retention coefficients, a, have been derived for the following compounds: pentane, 0.76 ± 0.09; isoprene, 0.66 ± 0.04; acetone, 0.17 ± 0.03; ammonia, 0.70 ± 0.13, methanol, 0.29 ± 0.02; formaldehyde, 0.06 ± 0.03; deuterated water (HDO), 0.09 ± 0.02. From these data, correction to breath analyses for inhaled concentration can be described by coefficients specific to each compound, which can be close to 1 for hydrocarbons, as applied by Phillips, or around 0.1, meaning that inhaled concentrations of such compounds can essentially be neglected. A further deduction from the experimental data is that under conditions of the inhalation of clean air, the measured exhaled breath concentrations of those compounds should be increased by a factor of 1/(1 - a) to correspond to gaseous equilibrium with the compounds dissolved in the mixed venous blood entering the alveoli. Thus, for isoprene, this is a factor of 3, which we have confirmed experimentally by re-breathing experiments.

As a contribution to the continuing search for breath biomarkers of lung and airways infection in patients with cystic fibrosis, CF, we have analysed the volatile metabolites released in vitro by Pseudomonas aeruginosa and other bacteria involved in respiratory infections in these patients, i.e. those belonging to the Burkholderia cepacia complex, Staphylococcus aureus or Stenotrophomonas maltophilia. These opportunistic pathogens are generally harmless to healthy people but they may cause serious infections in patients with severe underlying disease or impaired immunity such as CF patients. Volatile organic compounds emitted from the cultures of strains belonging to the above-mentioned four taxa were analysed by selected ion flow tube mass spectrometry. In order to minimize the effect of differences in media composition all strains were cultured in three different liquid media. Multivariate statistical analysis reveals that the four taxa can be well discriminated by the differences in the headspace VOC concentration profiles. The compounds that should be targeted in breath as potential biomarkers of airway infection were identified for each of these taxa of CF pathogens.

Stimulated by reading the recent article (Thekedar et al 2011 J. Breath Res. 5 016001) we are constrained to comment on some essential aspects of the terminology, interpretation and analysis of proton transfer reaction mass spectrometry (PTR-MS) data therein in an attempt to provide suggestions that will allow more rigorous application of PTR-MS to breath research and other areas. Additionally, we comment on the sampling methodology and protocols used and suggest that such experiments are most useful when compound identification is reliable. Finally, we propose that the challenging problems of identification and quantification of trace breath biomarkers related to patho-physiological conditions rather than the details of breath sampling should now become the priority for further breath analysis research.

We have carried out a selected ion flow tube mass spectrometry (SIFT-MS) study of the concentrations of the sulfur-containing compounds H(2)S (using H(3)O(+) precursor ions), CH(3)SH (H(3)O(+)), (CH(3))(2)S (O(2)(+)), (CH(3))(2)S(2) (NO(+)) and CS(2) (O(2)(+)) in single exhalations of mouth-exhaled breath and nose-exhaled breath and in the static gas in the oral cavity for two healthy volunteers. The primary purpose of the study was to show how compounds present in breath at levels as low as a part per billion (ppb) can be identified and quantified if the overlap of 'impurity' isobaric ions with the analytical product ions for each trace compound is identified and accounted for. The H(2)S measurements are straightforward using H(3)O(+) precursor ions, since no overlapping ions are recognized and its breath concentration is relatively high at typically 20-70 ppb. Thus, its concentration distribution for two healthy volunteers has been obtained over a period of a few weeks. The situation is very similar for CH(3)SH, but to analyse this compound we had to study the kinetics of its reactions with the SIFT-MS reagent ions H(3)O(+), NO(+) and O(2)(+) in order to provide the required kinetics library data for this compound. It is seen that CH(3)SH, (CH(3))(2)S and (CH(3))(2)S(2) are present in the mouth breath/cavity at lower levels of10 ppb. The measurements of the levels of H(2)S and these compounds in the nose-exhaled breath and the closed mouth indicate that they are largely produced in the oral cavity, although there is some indication that (CH(3))(2)S is partially systemic in these two volunteers. It was not possible to quantify CS(2) in the breath because of serious interference (overlapping ions) due to the presence of carbon dioxide and acetone that inevitably occur in exhaled breath. This study paves the way for the accurate analysis of these sulfur compounds in halitosis and potentially for probing the diseased state, especially liver disease, by breath analysis. To demonstrate the simplicity of measuring these compounds when they are present at levels of about 100 ppb and greater, data are presented on the emissions of these sulfur-containing compounds from Pseudomonas bacterial cultures in vitro.

The published results of breath isoprene studies, to date largely involving adults, are briefly reviewed with special attention given to the work done on this topic during the last 10 years using selected ion flow tube mass spectrometry, SIFT-MS. Then the new data recently obtained on isoprene levels in the exhaled breath of some 200 healthy children and young adults (pupils) with ages ranging from 7 to 18 years measured using SIFT-MS are presented in detail. A concentration distribution has been constructed from the data obtained and compared to that for healthy adults also obtained from SIFT-MS data. Although there is overlap between the two distributions, which are close to log normal in both cases, the median level for the young cohort is much lower at 37 parts-per-billion, pbb, geometric standard deviation, GSD, 2.5, compared to that for the adult cohort of 106 ppb with a GSD of 1.65. Further to this, there is a clear increase in the mean breath isoprene concentration with age for the young cohort with a doubling of the level about every 5-6 years until it reaches the age-invariant mean level of that for adult cohort. Should this trend be extrapolated downwards in age it would indicate a near-zero breath isoprene in the newborn that was indicated by a previous study. Indeed, in the present study isoprene was not detected on the breath of two young children. The results reveal mean breath isoprene levels (±SD) for pupils within the given age ranges as 7-10 years (28 ± 24 ppb), 10-13 years (40 ± 21 ppb), 13-16 years (60 ± 41 ppb) and 16-19 years (54 ± 31 ppb). The more rapid increase that occurs between the second and third age ranges is statistically highly significant (p = 0.001) and we attribute this phenomenon to the onset of puberty and the spurt in growth that occurs during this phase of development. There is no significant difference in mean breath isoprene between males and females for both the adult cohort and the younger cohort.

Original on-line measurements of acetone, ammonia and hydrogen cyanide in the exhaled breath of several volunteers within the age ranges 4-6 years and 60-83 years are reported and compared with previous data on volunteer cohorts covering ages 17-18 years and 20-60 years. The compiled data show that a significant statistical increase in breath ammonia occurs with increasing age, but that acetone and hydrogen cyanide do not vary greatly with age.

The aim of the present study was to characterize the volatile metabolites produced by genotypically diverse strains of the Stenotrophomonas genus in order to evaluate their potential as biomarkers of lung infection by non-invasive breath analysis. Volatile organic compounds (VOCs) emitted from 15 clinical and five environmental strains belonging to different genogroups of Stenotrophomonas maltophilia (n = 18) and Stenotrophomonas rhizophila (n = 2) cultured in Mueller-Hinton Broth (MHB) liquid media were analysed by gas chromatography mass spectrometry (GC-MS) and selected ion flow tube mass spectrometry (SIFT-MS). Several VOCs were detected in high concentration, including ammonia, propanol, dimethyl disulphide propanol and dimethyl disulphide. The GC-MS measurements showed that all 15 clinical strains produced similar headspace VOCs compositions, and SIFT-MS quantification showed that the rates of production of the VOCs by the genotypically distinct strains were very similar. All in vitro cultures of both the Stenotrophomonas species were characterised by efficient production of two isomers of methyl butanol, which can be described by known biochemical pathways and which is absent in other pathogens, including Pseudomonas aeruginosa. These in-vitro data indicate that methyl butanol isomers may be exhaled breath biomarkers of S. maltophilia lung infection in patients with cystic fibrosis.

The objective of this experimental study was to discover volatile metabolites present in exhaled breath that could be used as biomarkers of gastro-esophageal reflux disease, GERD, one of the most common causes of chronic cough. An in vitro model based on pork tissue samples exposed to a challenge by artificial gastric fluid was used to identify specific volatile compounds to be chosen for quantification in directly exhaled breath of GERD patients and controls using selected ion flow tube mass spectrometry, SIFT-MS. GC/MS analyses of the headspace of this in vitro model indicated that the only volatile compound significantly increased was acetic acid. End expiratory concentration of acetic acid measured by SIFT-MS in mouth exhaled breath of 22 GERD patients (median 85 ppbv) was found to be significantly higher than that in breath of a control group (median 48 ppbv). Breath acetic acid may be useful for non-invasive diagnostics of GERD and other conditions resulting in the lowering of pH of the lining of the airways.

Elevated concentrations of hydrogen cyanide (HCN) have been detected in the headspace of Pseudomonas aeruginosa (PA) cultures and in the breath of children with cystic fibrosis (CF) and PA infection. The use of mouth-exhaled breath HCN as a marker of PA infection in adults is more difficult to assess as some without PA infection generate HCN in their mouths. The analysis of breath exhaled via the nose, thereby avoiding volatile compounds produced in the mouth, will demonstrate elevated concentrations of HCN in adult CF patients chronically infected with PA. Using selected ion flow mass spectrometry (SIFT-MS), the mouth and the nose-exhaled breaths of 20 adult CF patients; 10 with chronic PA infection and 10 free from PA infection, were analysed for HCN. Acetone and ethanol were also measured as controls. SIFT-MS allows direct sampling and analysis of single breath exhalations, obviating the need to collect samples into bags or onto traps, which can compromise samples. HCN was detected in the mouth-exhaled breath of patients in both groups and in the nose-exhaled breath of patients with chronic PA infection. The difference in median (IQR) nose-exhaled HCN between the groups is statistically significant (11 (0.8-18) ppbv versus 0 (0-3.2) ppbv, p = 0.03). The concentrations of acetone and ethanol in nose-exhaled and mouth-exhaled breath are in keeping with previous studies. HCN in nose-exhaled breath is a biomarker of chronic airway infection with PA in adults with CF. Its application as a non-invasive diagnostic test for early PA infection warrants further investigation.

The results of experiments are described in which a known quantity of sterile deuterated water is injected directly into the pulmonary circulation via the right internal jugular vein of several haemodialysis patients and the deuterium to hydrogen ratio, D/H, in the exhaled lung water was measured using the flowing afterglow mass spectrometry technique. The breath D/H abundance was measured in sequential breath exhalations before and after the injection, providing data that are sufficiently detailed to follow the production and loss rate of D/H in the exhaled breath. Thus, in principle, considering isotope dilution the volume of water in the lungs and pulmonary circulation can be derived. However, it is seen that the maximum abundance that the breath D/H reached was much lower than anticipated by considering the likely volume of blood/water in the pulmonary circulation and so it is deduced that either 'leakage' of the injected deuterated water rapidly occurs from the pulmonary to the systemic circulation and/or isotope exchange of deuterium with hydrogen along the bronchial tree efficiently occurs, thus reducing the D/H in the exhaled breath. This latter phenomenon has important implications to breath analysis in which it is often assumed that so-called alveolar breath concentrations of metabolites reflect blood/systemic levels. Detailed consideration of the breath D/H abundances when the deuterium is equilibrated amongst the total body water, TBW, of the patients, which occurs about 40 min after injection of the deuterated water, allows the TBW of the patients to be estimated.

The SPACE study will assess exhaled breath hydrogen cyanide (HCN) concentrations as a marker of Pseudomonas aeruginosa (PA) infection in 240 children with cystic fibrosis (CF). It will use off-line selected ion flow tube mass spectrometry (SIFT-MS) analysis and so we needed to investigate which breath sampling bag material to use, the maximum storage time before analysis and the benefit of warming the bag samples. We studied 15 children with CF, 8 had chronic PA infection and 7 did not. Each exhaled directly into the instrument (on-line) and also into two 25 µm thick Nalophan (25N), two 70 µm Nalophan (70N) and two Tedlar® bags. Bags were stored at 20 or 37 °C. HCN concentrations were analysed at 1, 6, 24 and 48 h (off-line). Acetone and water vapour concentrations were also measured in parallel. Correlation between on-line and off-line concentrations measured by SIFT-MS was better for all compounds and bag types at 37 °C. The median (IQR) on-line HCN concentration was 8.9(4.4-13.7) parts per billion by volume, ppbv. Both on-line and off-line HCN concentrations were significantly higher in patients with PA infection than those without. At 37 °C the correlation between on-line and off-line HCN concentrations was good up to 6 h in the 25N bag (R(2) = 0.79) and up to 24 h for the 70N and Tedlar bags (R(2) = 0.82 and 0.86). The correlation between on- and off-line acetone concentrations at 37 °C was good up to 24 h in 25N, 70N and Tedlar bags (R(2) = 0.89, 0.93 and 0.97). In all three types of bag the water vapour concentration fell quickly and by 24 h was equivalent to that of lab air. Samples stored in Tedlar or 70N bags, warmed to 37 °C and analysed within 24 h, give HCN and acetone concentrations which correlate well with on-line measurements.

Although it has been known for centuries that there are compounds in exhaled breath that are altered in disease, it is only in the last few decades that it has been possible to measure them with sufficient accuracy and precision to make them clinically useful. The clinical utility of breath analysis has also been limited by the practical difficulties of collecting representative breath samples, free from contaminants. More recent methods of breath analysis have allowed real-time analysis of breath, eliminating the need for sample collection, and therefore potentially allowing the rapid feedback of results to patient and clinician. One possible future application of breath analysis may be the monitoring of metabolic control in patients with diabetes mellitus. This perspective article provides an overview of the studies of breath analysis in diabetes, focusing on the breath metabolites; acetone, isoprene and also methyl nitrate that have previously been reported to be altered in diabetes, highlighting the factors that may potentially confound their interpretation. Specific attention is given to selected ion flow tube mass spectrometry (SIFT-MS) and proton transfer reaction mass spectrometry (PTR-MS), because they are techniques that have been developed specifically for the absolute quantification of breath metabolites in real time, although reference is made to some of the alternative techniques, including sensors and optical devices. Whilst breath analysis, using SIFT-MS, PTR-MS and other sensitive techniques, can potentially be used for the non-invasive monitoring of metabolic conditions that may include diabetes mellitus, further work is required in terms of the clinical and analytical validation. Furthermore, it is unclear at present what breath metabolites should be monitored and what factors may confound their interpretation. Although a non-invasive method of monitoring glycaemic control is clearly desirable, it will be important to demonstrate its analytical comparability with the well-established and validated methods for blood glucose measurement.

Using selected ion flow tube mass spectrometry (SIFT-MS), measurements have been made of the levels of several metabolites in the exhaled breath of 200 healthy school children. Thus, concentration distributions of each metabolite have been obtained for the first time in the paediatric age range. The median values (in parentheses) of the concentrations in parts per billion, ppb, were ammonia (628), acetone (297), methanol (193), ethanol (187), isoprene (37), propanol (16), acetaldehyde (23) and pentanol (15). Hydrogen cyanide was not present in the breath above the detection limit of 2 ppb in the majority of subjects. The water vapour level (humidity) of the breath samples was routinely measured as a check on the sample integrity. Such data are essential if SIFT-MS breath analyses are to be used as a clinical tool to aid diagnosis and/or as a monitor of disease in children. The levels of metabolites usually followed a log-normal distribution and the levels of some compounds were similar to those obtained previously in adults. Lower values were found in the levels of acetone, ammonia, methanol and isoprene. There were no major variations in relation to gender. Some metabolites showed significant variation in relation to age and body mass index. To our knowledge, these are the first measurements of exhaled mouth breath pentanol levels. The median ammonia levels in mouth-exhaled breath of these children decreased with age, whereas in older adults, ammonia has been shown to increase with age. Breath acetone levels were significantly increased for those who had not eaten for more than 6 h prior to providing the breath sample, although dietary control was not a mandatory aspect of the protocol.

Analyses have been performed, using on-line selected ion flow tube mass spectrometry (SIFT-MS), of the breath of three healthy volunteers, as exhaled via the mouth and the nose and also of the air in the oral cavity during breath hold, each morning over a period of one month. Nine trace compounds have been quantified and concentration distributions have been constructed. Of these compounds, the levels of acetone, methanol and isoprene are the same in the mouth-exhaled and the nose-exhaled breath; hence, we deduce that these compounds are totally systemic. The levels of ammonia, ethanol and hydrogen cyanide are much lower in the nose-exhaled breath than in the mouth-exhaled breath and highest in the oral cavity, indicating that these compounds are largely generated in the mouth with little being released at the alveolar interface. Using the same ideas, both the low levels of propanol and acetaldehyde in mouth-exhaled breath appear to have both oral and systemic components. Formaldehyde is at levels in mouth- and nose-exhaled breath and the oral cavity that are lower than that of the ambient air and so its origin is difficult to ascertain, but it appears to be partially systemic. These results indicate that serious contamination of alveolar breath exhaled via the mouth can occur and if breath analysis is to be used to diagnose metabolic disease then analyses should be carried out of both mouth- and nose-exhaled breath to identify the major sources of particular trace compounds.

The sensitivity of selected ion flow tube mass spectrometry, SIFT-MS, has been increased such that it is now possible to detect metabolites present at a part-per-billion, ppb, level in single breath exhalations. However, to utilize this improved sensitivity, the overlaps (coincidences) of those ions resulting from interfering reactions of impurity precursor ions with some breath metabolites present at higher concentrations with the analytical product ions characteristic of particular metabolites must be accounted for. In this paper, the full reaction schemes are presented for SIFT-MS analyses of three volatile potential cancer biomarkers in exhaled breath, namely formaldehyde, HCHO, acetaldehyde, CH(3)CHO and 2-propanol, CH(3)CH(OH)CH(3), which identify both the characteristic SIFT-MS product ions for these compounds and the interfering ions at the same mass-to-charge, m/z, values. An absolute quantification equation accounting for these interferences is formulated and appropriate entries into the SIFT-MS kinetics library are indicated. It is shown that when using H(3)O(+) to quantify formaldehyde and acetaldehyde the reactions of impurity O(2)(+) ions with methanol and ethanol (always present in breath) must be accounted for and that the quantification of acetaldehyde must avoid the interference of the CO(2) present in exhaled breath. Finally, it is indicated that the analysis of 2-propanol can be achieved using both H(3)O(+) and NO(+) precursor ions.

A pilot study has been carried out to define typical characteristics of the trace gas compounds in exhaled breath of non-smokers and smokers to assist interpretation of breath analysis data from patients who smoke with respiratory diseases and lung cancer. Exhaled breath was analyzed using proton transfer reaction-mass spectrometry (PTR-MS) for 370 volunteers (81 smokers, 210 non-smokers, 79 ex-smokers). Volatile organic compounds corresponding to product ions at seven mass-to-charge ratios (m/z 28, 42, 69, 79, 93, 97, 123) in the PTR-MS spectra differentiated between smokers and non-smokers. The Youden index (= maximum of sensitivity + specificity - 1, YI) as a measure for differentiation between smokers and non-smokers was YI = 0.43 for ions at the m/z values 28 (tentatively identified as HCN), YI = 0.75 for m/z = 42 (tentatively identified as acetonitrile) and YI = 0.53 for m/z = 79 (tentatively identified as benzene). No statistically significant difference between smokers and non-smokers was observed for the product ions at m/z = 31 and 33 (compounds tentatively identified as formaldehyde and methanol). When interpreting the exhaled breath of lung cancer or COPD patients, who often smoke, compounds appearing at the above-mentioned seven mass-to-charge ratios should be considered with appropriate care to avoid misdiagnosis. Validation studies in larger numbers of patients with more precise delineation of their smoking behavior and using additional analytical techniques such as GC/MS and SIFT-MS should be carried out.

The data obtained for the concentration distributions of the most abundant volatile metabolites in exhaled breath determined in two independent studies are reviewed, the first limited study involving five healthy volunteers providing daily breath samples over a month, and the subsequent study involving 30 healthy volunteers providing breath samples weekly over six months. Both studies were carried out using selected ion flow tube mass spectrometry, SIFT-MS, to obtain on-line, real-time analyses of single breath exhalations, avoiding the complications associated with sample collection. The distributions of the metabolites from the larger more comprehensive study are mostly seen to be log normal with the median values (in parts per billion, ppb) being ammonia (833), acetone (477), methanol (461), ethanol (112), propanol (18), acetaldehyde (22), isoprene (106) with the geometric standard deviation being typically 1.6, except for ethanol which was larger (3.24) due to the obvious increase of breath ethanol following the ingestion of sugar. These were the first well-defined concentration distributions of breath metabolites obtained and they are the essential requirement for recognizing abnormally high levels that are associated with particular diseases. The associations of each metabolite with known diseased states are alluded to. These SIFT-MS studies reveal the promise of breath analysis as a valuable addition to the tools for clinical diagnosis and therapeutic monitoring.