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1.
Exhaled volatile organic compounds and respiratory disease : recent progress and future outlook
Maria Chiara Magnano, Waqar Ahmed, Ran Wang, Martina Bergant Marušič, Stephen J. Fowler, Iain R. White, 2024, review article

Abstract: The theoretical basis of eVOCs as biomarkers for respiratory disease diagnosis is described, followed by a review of the potential biomarkers that have been proposed as targets from in vitro studies. The utility of these targets is then discussed based on comparison with results from clinical breath studies. The current status of breath research is summarised for various diseases, with emphasis placed on quantitative and targeted studies. Potential for bias highlights several important concepts related to standardization, including practices adopted for compound identification, correction for background inspired VOC levels and computation of mixing ratios. The compiled results underline the need for targeted studies across different analytical platforms to understand how sampling and analytical factors impact eVOC quantification. The impact of environmental VOCs as confounders in breath analysis is discussed alongside the potential that eVOCs have as biomarkers of air pollution exposure and future perspectives on clinical breath sampling are provided.
Keywords: breath analysis, disease diagnosis, exhaled volatile organic compounds, respiratory disease, environmental exposure analysis, breath analysis
Published in RUNG: 06.05.2024; Views: 392; Downloads: 3
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2.
Changes in exhaled volatile organic compounds following indirect bronchial challenge in suspected asthma
Adam Peel, Ran Wang, Waqar Ahmed, Iain R. White, Maxim Wilkinson, Yoon K. Loke, Andrew M. Wilson, Stephen J. Fowler, 2023, original scientific article

Abstract: Background Inhaled mannitol provokes bronchoconstriction via mediators released during osmotic degranulation of inflammatory cells, and, hence represents a useful diagnostic test for asthma and model for acute attacks. We hypothesised that the mannitol challenge would trigger changes in exhaled volatile organic compounds (VOCs), generating both candidate biomarkers and novel insights into their origin. Methods Participants with a clinical diagnosis of asthma, or undergoing investigation for suspected asthma, were recruited. Inhaled mannitol challenges were performed, followed by a sham challenge after 2 weeks in participants with bronchial hyper-responsiveness (BHR). VOCs were collected before and after challenges and analysed using gas chromatography–mass spectrometry. Results Forty-six patients (mean (SD) age 52 (16) years) completed a mannitol challenge, of which 16 (35%) were positive, and 15 of these completed a sham challenge. Quantities of 16 of 51 identified VOCs changed following mannitol challenge (p<0.05), of which 11 contributed to a multivariate sparse partial least square discriminative analysis model, with a classification error rate of 13.8%. Five of these 16 VOCs also changed (p<0.05) in quantity following the sham challenge, along with four further VOCs. In patients with BHR to mannitol distinct postchallenge VOC signatures were observed compared with post-sham challenge. Conclusion Inhalation of mannitol was associated with changes in breath VOCs, and in people with BHR resulted in a distinct exhaled breath profile when compared with a sham challenge. These differentially expressed VOCs are likely associated with acute airway inflammation and/or bronchoconstriction and merit further investigation as potential biomarkers in asthma.
Keywords: asthma, exhaled volatile organic compounds, pulmonology, breath metabolomics
Published in RUNG: 31.07.2023; Views: 1157; Downloads: 3
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3.
Microbial volatiles as diagnostic biomarkers of bacterial lung infection in mechanically ventilated patients
Waqar M Ahmed, Dominic Fenn, Iain R. White, Breanna Dixon, Tamara M E Nijsen, Hugo H Knobel, Paul Brinkman, Pouline M P van Oort, Marcus J Schultz, Paul Dark, Royston Goodacre, Timothy Felton, Lieuwe D J Bos, Stephen J. Fowler, 2022, original scientific article

Abstract: Background Early and accurate recognition of respiratory pathogens is crucial to prevent increased risk of mortality in critically ill patients. Microbial-derived volatile organic compounds (mVOCs) in exhaled breath could be used as non-invasive biomarkers of infection to support clinical diagnosis. Methods In this study, we investigated the diagnostic potential of in vitro confirmed mVOCs in the exhaled breath of patients under mechanically ventilation from the BreathDx study. Samples were analysed by thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS). Results Pathogens from bronchoalveolar lavage (BAL) cultures were identified in 45/89 patients and S. aureus was the most commonly identified pathogen (n = 15). Out of 19 mVOCs detected in the in vitro culture headspace of four common respiratory pathogens (Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli), 14 were found in exhaled breath samples. Higher concentrations of two mVOCs were found in the exhaled breath of patients infected with S. aureus compared to those without (3-methylbutanal p < 0.01. AUROC = 0.81-0.87 and 3-methylbutanoic acid p = 0.01. AUROC = 0.79-0.80). In addition, bacteria identified from BAL cultures which are known to metabolise tryptophan (Escherichia coli, Klebsiella oxytoca and Haemophilus influenzae) were grouped and found to produce higher concentrations of indole compared to breath samples with culture-negative (p = 0.034) and other pathogen-positive (p = 0.049) samples. Conclusions This study demonstrates the capability of using mVOCs to detect the presence of specific pathogen groups with potential to support clinical diagnosis. Although not all mVOCs were found in patient samples within this small pilot study, further targeted and qualitative investigation is warranted using multi-centre clinical studies.
Keywords: Breath, VOCs, infection, respiratory pathogens, VAP
Published in RUNG: 28.11.2022; Views: 1474; Downloads: 0
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4.
Composition and diversity analysis of the lung microbiome in patients with suspected ventilator-associated pneumonia
Dominic Fenn, Mahmoud Abdel-Aziz, Pouline van Oort, Paul Brinkman, Waqar Ahmed, Timothy Felton, Antonio Artigas, Pedro Póvoa, Ignacio Martin-Loeches, Marcus Schultz, Paul Dark, Stephen Fowler, Iain R. White, 2022, original scientific article

Abstract: Background: Ventilator-associated pneumonia (VAP) is associated with high morbidity and health care costs, yet diagnosis remains a challenge. Analysis of airway microbiota by amplicon sequencing provides a possible solution, as pneumonia is characterised by a disruption of the microbiome. However, studies evaluating the diagnostic capabilities of microbiome analysis are limited, with a lack of alignment on possible biomarkers. Using bronchoalveolar lavage fluid (BALF) from ventilated adult patients suspected of VAP, we aimed to explore how key characteristics of the microbiome differ between patients with positive and negative BALF cultures and whether any differences could have a clinically relevant role. Methods: BALF from patients suspected of VAP was analysed using 16s rRNA sequencing in order to: (1) differentiate between patients with and without a positive culture; (2) determine if there was any association between microbiome diversity and local inflammatory response; and (3) correctly identify pathogens detected by conventional culture. Results: Thirty-seven of 90 ICU patients with suspected VAP had positive cultures. Patients with a positive culture had significant microbiome dysbiosis with reduced alpha diversity. However, gross compositional variance was not strongly associated with culture positivity (AUROCC range 0.66–0.71). Patients with a positive culture had a significantly higher relative abundance of pathogenic bacteria compared to those without [0.45 (IQR 0.10–0.84), 0.02 (IQR 0.004–0.09), respectively], and an increased interleukin (IL)-1β was associated with reduced species evenness (rs = − 0.33, p < 0.01) and increased pathogenic bacteria presence (rs = 0.28, p = 0.013). Untargeted 16s rRNA pathogen detection was limited by false positives, while the use of pathogen-specific relative abundance thresholds showed better diagnostic accuracy (AUROCC range 0.89–0.998). Conclusion: Patients with positive BALF culture had increased dysbiosis and genus dominance. An increased caspase-1-dependent IL-1b expression was associated with a reduced species evenness and increased pathogenic bacterial presence, providing a possible causal link between microbiome dysbiosis and lung injury development in VAP. However, measures of diversity were an unreliable predictor of culture positivity and 16s sequencing used agnostically could not usefully identify pathogens; this could be overcome if pathogen-specific relative abundance thresholds are used.
Keywords: Microbiome, Next-generation sequencing, Ventilator-associated pneumonia
Published in RUNG: 26.10.2022; Views: 1246; Downloads: 0
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5.
Breath and plasma metabolomics to assess inflammation in acute stroke
Waqar Ahmed, Iain R. White, Maxim Wilkinson, Craig Johnson, Nicholas J. W. Rattray, Amit K. Kishore, Royston Goodacre, Craig J. Smith, Stephen J. Fowler, 2021, original scientific article

Abstract: Inflammation is strongly implicated in both injury and repair processes occurring after stroke. In this exploratory study we assessed the feasibility of repeated sampling of exhaled volatile organic compounds and performed an untargeted metabolomic analysis of plasma collected at multiple time periods after stroke. Metabolic profiles were compared with the time course of the inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6). Serial breath sampling was well-tolerated by all patients and the measurement appears feasible in this group. We found that exhaled decanal tracks CRP and IL-6 levels post-stroke and correlates with several metabolic pathways associated with a post-stroke inflammatory response. This suggests that measurement of breath and blood metabolites could facilitate development of novel therapeutic and diagnostic strategies. Results are discussed in relation to the utility of breath analysis in stroke care, such as in monitoring recovery and complications including stroke associated infection.
Keywords: stroke, metabolomics, breath, VOCs, inflammation
Published in RUNG: 18.11.2021; Views: 1876; Downloads: 62
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6.
The peppermint breath test: a benchmarking protocol for breath sampling and analysis using GC-MS
Maxim Wilkinson, Iain R. White, Katie Hamshere, Olaf Holz, Sven Schuchardt, Francesca G. Bellagambi, Tommaso Lomonaco, Denise Biagini, Laura Di Francesco, Stephen J. Fowler, 2020, original scientific article

Abstract: Exhaled breath contains hundreds of volatile organic compounds (VOCs) which offers the potential for diagnosing and monitoring a wide range of diseases. As the breath research field has grown, sampling and analytical practices have become highly varied between groups. Standardisation would allow meta-analyses of data from multiple studies and greater confidence in published results. The Peppermint Consortium has been formed to address this task of standardisation. In the current study we aimed to generate initial benchmark values for thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS) analysis of breath samples containing peppermint-derived VOCs. Headspace analysis of peppermint oil capsules was performed to determine compounds of interest. Ten healthy participants were recruited by three groups. Each participant provided a baseline breath sample prior to taking a peppermint capsule, with further samples collected at 60, 90, 165, 285 and 360 min following ingestion. Sampling and analytical protocols were different for each institution, in line with their usual practice. Samples were analysed by TD-GC-MS and benchmarking values determined for the time taken for detected peppermint VOCs to return to baseline values. Sixteen compounds were identified in the capsule headspace. Additionally, 2,3-dehydro-1,8-cineole was uniquely found in the breath samples, with a washout profile that suggested it was a product of peppermint metabolism. Five compounds (α-pinene, β-pinene, eucalyptol, menthol and menthone) were quantified by all three groups. Differences in recovery were observed between the groups, particularly for menthone and menthol. The average time taken for VOCs to return to baseline was selected as the benchmark and were 441, 648, 1736, 643 and 375 min for α-pinene, β-pinene, eucalyptol, menthone and menthol respectively. An initial set of easy-to-measure benchmarking values for assessing the performance of TD-GC-MS systems for the analysis of VOCs in breath is presented. These values will be updated when more groups provide additional data.
Keywords: Volatile organic compounds, breath, diagnostics, standardisation
Published in RUNG: 11.12.2020; Views: 3299; Downloads: 0
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7.
Detection and quantification of exhaled volatile organic compounds in mechanically ventilated patients–comparison of two sampling methods
Iain R. White, Pouline M. van Oort, Waqar Ahmed, Craig Johnson, Jonathan Bannard-Smith, Timothy Felton, Lieuwe D. Bos, Royston Goodacre, Paul Dark, Stephen J. Fowler, 2020, original scientific article

Abstract: Exhaled breath analysis is a promising new diagnostic tool, but currently no standardised method for sampling is available in mechanically ventilated patients. We compared two breath sampling methods, first using an artificial ventilator circuit, then in “real life” in mechanically ventilated patients on the intensive care unit. In the laboratory circuit, a 24-component synthetic-breath volatile organic compound (VOC) mixture was injected into the system as air was sampled: (A) through a port on the exhalation limb of the circuit and (B) through a closed endo-bronchial suction catheter. Sorbent tubes were used to collect samples for analysis by thermal desorption-gas chromatography-mass spectrometry. Realistic mechanical ventilation rates and breath pressure–volume loops were established and method detection limits (MDLs) were calculated for all VOCs. Higher yields of VOCs were retrieved using the closed suction catheter; however, for several VOCs MDLs were compromised due to the background signal associated with plastic and rubber components in the catheters. Different brands of suction catheter were compared. Exhaled VOC data from 40 patient samples collected at two sites were then used to calculate the proportion of data analysed above the MDL. The relative performance of the two methods differed depending on the VOC under study and both methods showed sensitivity towards different exhaled VOCs. Furthermore, method performance differed depending on recruitment site, as the centres were equipped with different brands of respiratory equipment, an important consideration for the design of multicentre studies investigating exhaled VOCs in mechanically ventilated patients.
Keywords: Volatile organic compounds, infection, breath, ventilator associated pneumonia
Published in RUNG: 10.12.2020; Views: 2710; Downloads: 0
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8.
Effects of high relative humidity and dry purging on VOCs obtained during breath sampling on common sorbent tubes
Maxim Wilkinson, Iain R. White, Roy Goodacre, Tamara Nijsen, Stephen Fowler, 2020, original scientific article

Abstract: Offline breath analysis by thermal desorption gas chromatography mass spectrometry (TD-GC-MS) requires the use of sorbent traps to concentrate and store volatile compounds. The selection of which sorbent to use and best practices for managing high relative humidity are important considerations to allow for reproducible, untargeted, biomarker discovery in water saturated breath samples. This work aims to assess three commonly used sorbent materials for their use in breath volatile sampling and determine how the high relative humidity inherent in such samples effects the capture of volatile compounds of interest. TenaxGR, TenaxTA/Carbograph1TD and TenaxTA/Carbograph5TD tubes were selected as they are the most commonly used sorbents in the breath sampling literature. The recovery of 29 compounds in a standard mix loaded using high humidity gas was tested for each sorbent and compared to loading in dry gas. Water retention and dry purge rates were determined for each sorbent for 500 ml and 1000 ml breath collections. Finally, breath samples were collected simultaneously on to each sorbent type using the ReCIVA and analysed by TD-GC-MS. All three sorbents exhibited acceptable reproducibility when loaded with the standard mix in dry gas (RSD < 10%). Loading the standard mix in humid gas led to reduced recovery of compounds based on their chemical properties. Dry purging performance for each sorbent material was assessed and was shown to be 1.14, 1.13 and 0.89 mg H2O min−1 for TenaxGR, TenaxTA/Carbograph1TD and TenaxTA/Carbograph5TD respectively when flushed with 50 ml min−1 of N2. A comparison of breath profiles on different sorbents showed differences in background artefacts (sulfur dioxide, cyclopenten-1-one and 3-nonene) and endogenous breath compounds (2-methyl-furan and furfural). This work demonstrates that high relative humidity during sampling reduces the ability of sorbent tubes to capture volatile compounds and could impact method detection limits during breath sampling. Sufficient water to impair accurate analysis was retained on all tubes. Minimal differences were observed between sorbent materials when used to sample breath, however, suggestions are provided for sorbent selection for future studies.
Keywords: VOCs, Breath sampling, ReCIVA
Published in RUNG: 27.07.2020; Views: 3108; Downloads: 113
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9.
Circadian rhythm of exhaled biomarkers in health and asthma
Max Wilkinson, Robert Maidstone, Andrew Loudon, John Blaikley, Iain R. White, Dave Singh, David Ray, Royston Goodacre, Stephen Fowler, Hannah Durrington, 2019, original scientific article

Abstract: Circadian rhythms control many biological processes in the body in both health and disease. Greater understanding of diurnal variability in disease related biomarkers is crucial for their application in clinical practice and biomarkers of circadian rhythm are required to facilitate further research into disturbed chronicity. To determine if fractional exhaled nitric oxide and breath volatile biomarkers vary rhythmically during the day in healthy and asthmatic individuals. Ten individuals with moderate, atopic asthma (on regular inhaled corticosteroids) and 10 healthy volunteers (all non-smokers) completed an overnight visit where their exhaled breath volatiles and forced exhaled nitric oxide levels were collected every 6 h. Breath volatiles were analysed using gas chromatography mass spectrometry, after trapping these volatiles on sorbent materials for thermal desorption. Nine breath volatiles (including acetone and isoprene) exhibit diurnal variation across all individuals. Furthermore the circadian pattern of several VOCs is altered in individuals with asthma and fractional exhaled nitric oxide is rhythmic in asthma but not in healthy controls. Markers of circadian rhythm can be identified in breath and may offer insight into circadian profiling to help treat disease. Additionally this work suggests that time of day must be controlled when designing future biomarker discovery studies. Further work is required with larger cohorts to validate and extend these findings.
Keywords: VOCs, breath, asthma, circadian
Published in RUNG: 21.10.2019; Views: 3507; Downloads: 0
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10.
Capturing and Storing Exhaled Breath for Offline Analysis
Iain R. White, Stephen J. Fowler, 2019, independent scientific component part or a chapter in a monograph

Abstract: In this chapter we will summarize and discuss methods for the capture and storage of exhaled breath, prior to offline (and indirect online) analysis. We will detail and compare methods currently in use, including their applications, key strengths, and limitations. In synthesizing the best features of each technique, we will propose an ideal standardized breath sampling solution, and give a personal vision on the next steps to be taken in this exciting area of breath research.
Keywords: Breath analysis, Breath sampling, Offline analysis, Thermal desorption, Gas chromatography-mass spectrometry
Published in RUNG: 22.07.2019; Views: 3586; Downloads: 0
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