Thorax Online First, published on April 7, 2011 as 10.1136/thx.2011.161208 PostScript RESEARCH LETTER Background Modern gas analysis techniques permit real time and on-line quantification of multiple volatile trace gases within a single exhalation. However, the influence of various respiratory manoeuvres affecting exhalation flow and the kinetics of metabolite release to the gasphase remain largely unknown. Methods We examined variation in the concentrations of selected trace gases over a range of expiratory flows (50; 100; 250 ml/s) and after 30 second periods of breathold and paced hyperventilation. On-line measurement of breath samples from healthy volunteers (n¼10) was performed by proton transfer mass spectrometry. Results Exhaled acetone increased with higher expiratory flow rate (805, 838, 898 ppb, p¼0.02). Levels of methanol (206 vs 179 ppb, p<0.01), acetaldehyde (26 vs 22 ppb, p<0.01), ethanol (410 vs 208 ppb, p¼0.01) and dimethyl sulphide (113 vs 103 ncps, p<0.01) fell significantly following 30s hyperventilation. After 30 second breathold levels of methanol (206 vs 217 ppb, p¼0.02), acetone (805 vs 869 ppb, p<0.01), isoprene (348 vs 390 ppb, p¼0.02) and dimethyl sulphide (113 vs 136 ncps, p¼0.02) increased significantly. Variation in respiratory parameters did not significantly alters the level of acetonitrile, propanol and butyric acid within the breath of healthy subjects. Conclusions These findings demonstrate that respiratory manoeuvres significantly influence the measured concentration of a number of exhaled VOCs that are of potential importance within the clinical setting. Our results support the adoption of standardised practices for breath gas analysis by on-line and real time mass spectrometry methods. Analysis of volatile trace gases within exhaled breath, for the purpose of non-invasive disease detection and monitoring, is a rapidly emerging field of research.1 2 Recent technological developments such as proton transfer reaction‑mass spectrometry (PTR-MS) have allowed on-line and real-time detection of multiple trace gases in breath, leading to novel discoveries in cancer, infectious disease and metabolism.2 3 One of the greatest lessons on clinical applicability of breath analysis has been the recognition that multiple physiological variables can influence the quantification of exhaled nitric oxide (NO), necessitating international consensus guidelines for its standardised measurement.4 There remains however limited experimental evidence defining the impact of confounding factors which may influence the quantification of other exhaled volatile trace gases.5 Herein we present the finding of a study investigating the influence of respiratory variables on the on-line detection and quantification of a judiciously selected and potentially clinically relevant panel of expiratory trace gases. We examined the variation in the concentrations of selected trace gases (methanol, acetaldehyde, ethanol, acetone, isoprene, acetonitrile, propanol, dimethyl sulphide and butyric acid) over a range of expiratory flows (50, 100, 250 ml/s) and after the 30-s periods of breath hold and paced hyperventilation. These volatiles were compared to exhaled NO and carbon dioxide. On-line measurement of breath samples from healthy volunteers (n¼10) was performed by combining PTR-MS (Ionimed Analytik GmbH, Innsbruck, Austria) with the LR2500 multiple-gas analyser (Logan Research Ltd, Rochester, UK). Quantification of trace gases by PTR-MS was achieved by calibration experiments using accurately known gas standards and a purpose built gas Figure 1 Influence of respiratory physiological variables on the concentrations of selected trace gases measured within the exhaled breath of healthy volunteers. Trace gas level are presented as the ratio of the difference in breath manoeuvres versus their respective control breath measures at a flow rate of 50 ml/s. Boshier PR, Priest OH, Hanna GB, et(or al. Thorax doi:10.1136/thx.2011.161208 1 of 2 Copyright Article author their(2011). employer) 2011. Produced by BMJ Publishing Group Ltd (& BTS) under licence. Thorax: first published as 10.1136/thx.2011.161208 on 7 April 2011. Downloaded from http://thorax.bmj.com/ on June 4, 2020 by guest. Protected by copyright. Influence of respiratory variables on the on-line detection of exhaled trace gases by PTR-MS calibration unit (Ionimed). (Further details of methodology are provided as supplementary digital content). In contrast to NO, exhibiting an inverse relationship with expiratory flow rate, exhaled acetone increased with higher flows (805 vs 838, 898 ppb, p¼0.02) (figure 1). After a 30-s breath hold, levels of acetone (805 vs 869 ppb, p<0.01), methanol (206 vs 217 ppb, p¼0.02), isoprene (348 vs 390 ppb, p¼0.02) and dimethyl sulphide (113 vs 136 ncps, p¼0.02) increased significantly. Levels of methanol (206 vs 179 ppb, p<0.01), dimethyl sulphide (113 vs 103 ncps, p<0.01), acetaldehyde (26 vs 22 ppb, p<0.01) and ethanol (410 vs 208 ppb, p¼0.01) fell significantly following the 30-s hyperventilation (figure 1). Variation in respiratory parameters did not significantly alter the levels of acetonitrile, propanol and butyric acid (table 2 in online supplement). This work constitutes the first concerted attempt to discern the effect of ventilatory variables on breath analysis by an on-line MSbased analytical technique. The principal findings of this study are (i) PTR-MS evidence for the flow dependency of exhaled acetone; (ii) changing minute ventilation can both increase and decrease the concentrations of selected exhaled trace gases; and (iii) concentrations of certain volatiles were not PostScript Piers R Boshier,1 Oliver H Priest,1 George B Hanna,1 Nandor Marczin2,3 Medicine and Intensive Care, Imperial College London, Chelsea and Westminster Hospital, London, UK; 3 Department of Anaesthetics, Harefield Hospital, The Royal Brompton and Harefield NHS Foundation Trust, Harefield, Middlesex, UK Correspondence to Dr Nandor Marczin, Department of Surgery and Cancer, Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK; n.marczin@imperial.ac.uk 2 of 2 1. 2. 3. < An additional table is published online only. To view this file please visit the journal online (http://thorax.bmj.com). 4. Competing interests None. Ethics approval This study was conducted with the approval of the Riverside Research Ethics Committee (project reference number: 08/H0706/134). Provenance and peer review Not commissioned; externally peer reviewed. 1 Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital, London, UK; 2Department of Surgery and Cancer, Section of Anaesthetics, Pain REFERENCES Accepted 9 February 2011 5. Kharitonov SA, Barnes PJ. Exhaled biomarkers. Chest 2006;130:1541e6. Amann A, Smith D, eds. Breath Analysis for Clinical Diagnosis and Therapeutic Monitoring. Singapore: World Scientific, 2005. Lindinger W, Hansel A, Jordan A. On-line monitoring of volatile organic compounds at pptv levels by means of proton-transfer-reaction mass spectrometry (PTR-MS)-medical applications, food control and environmental research. Int J Mass Spectrom 1998;173:191e241. American Thoracic Society; European Respiratory Society. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med 2005;171:912e30. Larstad MA, Toren K, Bake B, et al. Determination of ethane, pentane and isoprene in exhaled air: effects of breath-holding, flow rate and purified air. Acta Physiol (Oxf) 2007;189:87e98. Thorax 2011;-:1e2. doi:10.1136/thx.2011.161208 Boshier PR, Priest OH, Hanna GB, et al. Thorax (2011). doi:10.1136/thx.2011.161208 Thorax: first published as 10.1136/thx.2011.161208 on 7 April 2011. Downloaded from http://thorax.bmj.com/ on June 4, 2020 by guest. Protected by copyright. significantly altered by respiratory manoeuvres in healthy volunteers. These preliminary observations may have important implications regarding the standardisation requirement for measuring and reporting the concentrations of exhaled trace gases in the future. Further larger studies both in healthy and diseased subjects are necessary to expand on these observations and to provide mechanistic insights into exchange kinetics of affected volatiles. Such studies may help to further define the exact role of on-line MS technologies in non-invasive diagnosis and monitoring pulmonary and systemic diseases.