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Exhaled Breath Analysis: a Review of ‘Breath-Taking’ Methods for Off-Line Analysis

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Exhaled Breath Analysis: a Review of ‘Breath-Taking’ Methods for Off-Line Analysis Metabolomics (2017) 13:110 DOI 10.1007/s11306-017-1241-8 REVIEW ARTICLE Exhaled breath analysis: a review of ‘breath-taking’ methods for off-line analysis Oluwasola Lawal1,2,3 · Waqar M. Ahmed1,2,3 · Tamara M. E. Nijsen2 · Royston Goodacre3 · Stephen J. Fowler1,4 Received: 1 April 2017 / Accepted: 24 July 2017 © The Author(s) 2017. This article is an open access publication Abstract in the area. In addition, the review will discuss and critique Background The potential of exhaled breath sampling and various breath sampling methods for off-line breath analysis. analysis has long attracted interest in the areas of medical Methods Literature search was carried out in databases diagnosis and disease monitoring. This interest is attributed MEDLINE, BIOSIS, EMBASE, INSPEC, COMPENDEX, to its non-invasive nature, access to an unlimited sample PQSCITECH, and SCISEARCH using the STN platform supply (i.e., breath), and the potential to facilitate a rapid at which delivers peer-reviewed articles. Keywords searched patient diagnosis. However, progress from laboratory setting for include breath, sampling, collection, pre-concentration, to routine clinical practice has been slow. Different method- volatile. Forward and reverse search was then performed on ologies of breath sampling, and the consequent difficulty in initially included articles. The breath collection methodolo- comparing and combining data, are considered to be a major gies of all included articles was subsequently reviewed. contributor to this. To fulfil the potential of breath analysis Results Sampling methods differs between research within clinical and pre-clinical medicine, standardisation of groups, for example regarding the portion of breath being some approaches to breath sampling and analysis will be targeted. Definition of late expiratory breath varies between beneficial. studies. Objectives The aim of this review is to investigate the het- Conclusions Breath analysis is an interdisciplinary field of erogeneity of breath sampling methods by performing an in study using clinical, analytical chemistry, data processing, depth bibliometric search to identify the current state of art and metabolomics expertise. A move towards standardisa- tion in breath sampling is currently being promoted within the breath research community with a view to harmonising analysis and thereby increasing robustness and inter-labo- Electronic supplementary material The online version of this ratory comparisons. article (doi:10.1007/s11306-017-1241-8) contains supplementary material, which is available to authorized users. Keywords Breath sampling · Breath phases · Breath * Stephen J. Fowler collection · Breath pre-concentration [email protected] 1 Abbreviations Division of Infection, Immunity and Respiratory Medicine, BCA Breath collection apparatus School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK CAR Carboxen CW Carbowax 2 Philips Research, Royal Philips B.V., Eindhoven, The Netherlands DVB Divinylbenzene DMS Differential mobility spectrometry 3 School of Chemistry, Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK ECD Electron capture detector FID Flame ionisation detector 4 Manchester Academic Health Science Centre, The University of Manchester and University Hospital of South Manchester GC-MS Gas chromatography-mass spectrometry NHS Foundation Trust, Manchester, UK MW Molecular weight Vol.:(0123456789)1 3 110 Page 2 of 16 O. Lawal et al. NTDs Needle trap devices state occurs and this can be detected and potentially uti- PA Polyacrylate lised for diagnosis and monitoring (Beale et al. 2016). The PDMS Polydimethylsiloxane origin of breath VOCs include the environment (termed ppmv Parts per million volume exogenous), the host (endogenous), and also the micro- ppbv Parts per billion volume biome (the microorganisms that inhabit the mouth, lung SPME Solid phase microextraction and gut) (Boots et al. 2015; Bos et al. 2013; Schulz and TD Thermal desorption Dickschat 2007). Most of the identified VOCs in exhaled Tof Time of flight breath originate exogenously (Costello et al. 2014), but VOCs Volatile organic compounds endogenous and microbial VOCs are of more interest clini- cally. Endogenous VOCs have the potential to provide a snapshot of the physiological state of an individual whilst 1 Introduction microbial VOCs could aid in pathogen identification, and the interaction of the host and commensal microorganisms Breath odours were used for disease recognition long contributes significant complexity to the metabolome of before present-day diagnostics; a sweet smell was associ- this complex “superorganism” (Goodacre 2007). Breath ated with diabetes mellitus, fish-like smell with liver disease, VOCs are found at trace levels [typically parts per mil- and urine-like smell with kidney disease (Phillips 1992). lion volume (ppmv) and lower] and their reliable detection Exhaled breath is predominantly composed of nitrogen, oxy- poses a challenge, hence the typical use of sample pre- gen, carbon dioxide, argon as well as water vapour, whereas concentration coupled with a highly sensitive analytical the volatile organic compounds (VOCs) which may be instrument. Several methods are utilised for pre-concen- diagnostically useful are only found in trace concentrations tration using thermal desorption chemistries such as solid (Lourenco and Turner 2014). Identification of VOCs pat- phase microextraction (SPME) and needle trap devices terns via human olfaction for disease diagnosis is of course (NTDs). subjective, and modern analytical instruments have sought The off-line breathomics pipeline can be broadly broken to make this more reliable and robust. This has led to a sus- down into breath sample collection, sample analysis, and tained interest in breath diagnosis due to its non-invasive data analysis (Rattray et al. 2014). There are several ways nature, with the ability to take repeat measurements with lit- of achieving the desired goal in each section. For example, tle stress or discomfort to the individual under investigation. for breath sample collection, factors such as type of breath The concept behind breath metabolomics (also known to be collected (i.e., mixed expiratory or end-tidal), single or as breathomics) is that the VOC profile in breath will be multiple exhalation, and choice of breath capture technology altered when a switch from a healthy to a pathological are just some of the options to be considered (Fig. 1). Fig. 1 A diagram illustrating the off-line breath sampling pipeline. desorption (TD) tube, needle trap devices (NTDs)]. Gas chromato- First section shows breath sampling containers [From L to R gas sam- graph (GC) and mass analysers [quadrupole, time-of-flight (Tof)] are pling bag, face-mask, Bio-VOC™ Sampler, breath collection appa- in the third section and the fourth section depicts targeted and untar- ratus (BCA), canister], second section indicates pre-concentration geted data pre-treatment, processing and analysis methods [From L to R solid phase microextraction (SPME), Thermal 1 3 Page 3 of 16 110 Exhaled breath analysis: a review of ‘breath-taking’ methods for off-line analysis In this article, a summary of methods utilised in the off- and reverse searching resulting in the final inclusion of 110 line breathomics pipeline across studies is shown, whilst papers. From the final 110 articles the following parameters evaluating heterogeneity between methods and suggesting were assessed: where standardisation may be beneficial. • Exhaled breath portion targeted • Breath collection container 2 Breathomics bibliography search criteria • Pre-concentration methods The search was conducted to include articles until the 24th A schematic representation of exhaled breath phases is of October 2016 and the overall process used is schemati- depicted in Fig. 2 and thus the breath type categories were cally shown in the supplementary material (Figure S1). To sub-categorised into: late expiratory breath (Table 1), sam- ensure quality, the STN platform (https://www.stn.org/stn/) pling from the end-tidal or ‘alveolar’ breath (Table 2), and was utilised which delivers peer reviewed articles only. mixed expiratory breath (Table 3). Other breath types can Databases searched include MEDLINE, BIOSIS, EMBASE, be found in the supplementary information (Table S1).These INSPEC, COMPENDEX, PQSCITECH, and SCISEARCH. tables include a brief description of how the breath type was The search strategy included looking for (breath?) in article obtained, and further categorisation was performed accord- titles and ((sampl? OR collect? OR pre(W)concentrat? OR ing to the type of breath collection container, as well as the preconcentrat?) AND volatile) in the title and abstracts of pre-concentration method employed in the study. articles. “?” and “W” denotes any number of characters to the right of the term and one character between two words (e.g. space or hyphen) respectively. In total, 395 manu- scripts were obtained after automatic filtration. These arti- 3 Sampling exhaled breath cles were subsequently manually filtered to exclude review articles, breath condensate articles, articles with only real During breath sampling, there is a choice made as to the time analytical platforms, and also non-human studies. In portion of the breath that can be collected, and this can be the scenario where the same breath sampling methodology broadly divided into late expiratory, end-tidal, and mixed is used
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