CME review

Human exhaled breath analysis

Todor A. Popov, MD, PhD

Objective: To review the fast-developing topic of assessment of exhaled breath components to improve the diagnosis and
monitoring of respiratory and systemic diseases.
Data Sources: Review of the literature available in monographs and journals.
Study Selection: Articles and overviews on the broad spectrum of existing experimental and routinely applied methods to
assess different aspects of human exhaled breath analysis were selected for presentation in this review.
Results: Exhaled breath constitutes more than 3,500 components, the bulk of which are volatile organic compounds in
miniature quantities. Many of these characterize the functioning of the organism as a whole (systemic biomarkers), but some are
related to processes taking place in the respiratory system and the airways in particular (lung biomarkers). Assessment of lung
biomarkers has proven useful in airway inflammatory diseases. It involves direct measurement of gases such as nitric oxide and
inflammatory indicators in exhaled breath condensate such as oxidative stress markers (eg, hydrogen peroxide and isoprostanes),
nitric oxide derivatives (eg, nitrate and nitrates), arachidonic acid metabolites (eg, prostanoids, leukotrienes, and epoxides),
adenosine, and cytokines. Integral approaches have also been suggested, such as exhaled breath temperature measurement and
devices of the “electronic nose” type, which enable the capture of approaches have also been suggested, such as exhaled breath
temperature measurementexhaled molecular fingerprints (breath prints). Technical factors related to standardization of the
different techniques need to be resolved to reach the stage of routine applicability.
Conclusions: Examination of exhaled breath has the potential to change the existing routine approaches in human medicine.
The rapidly developing new analytical and computer technologies along with novel, unorthodox ideas are prerequisites for future
advances in this field.
Ann Allergy Asthma Immunol. 2011;106:451– 456.

Off-label disclosure: Dr Popov has indicated that this article does not include the discussion of unapproved/investigative use of a commercial product/device.
Financial disclosure: Dr Popov has indicated that in the last 12 months he has not had any financial relationship, affiliation, or arrangement with any
corporate sponsors or commercial entities that provide financial support, education grants, honoraria, or research support or involvement as a consultant,
speaker’s bureau member, or major stock shareholder whose products are prominently featured either in this article or with the groups who provide general
financial support for this CME program.
Instructions for AMA PRA Category 1 CreditTM:
1. Read the CME review article in this issue carefully and complete the activity by answering the self-assessment examination questions on the form on page
2. To receive CME credit, submit the completed form to the ACAAI office prior to June 30, 2012.

INTRODUCTION the process of gas exchange taking place in the lung alveoli;
Biomarkers are quantifiable indicators of physiologic func- other moieties are released from the airways to join the mix.
tion and disease activity that provide a practical basis for More than 3,500 different components have been identified in
diagnosis and monitoring of pathologic states. They can be exhaled breath, with the list continually growing. Several of
measured in different media belonging or emanating from an them are gases, which constitute the bulk of the exhaled
organism. Circulating blood is pooling together biochemical breath volume: nitrogen, oxygen, water, and carbon dioxide.
compounds and metabolites released from different tissues. A Others are mostly volatile organic compounds (VOCs), and their
plethora of these are released in the ambient environment in concentration is miniature. Approximately 50% of the identified
VOCs are of endogenous origin, and approximately 200 of these
Affiliations: * Clinic of Allergy & Asthma, Medical University Sofia, trace compounds are detected in average breath samples from
Sofia, Bulgaria. the general human population.1 Different sets of compounds
Received for publication January 22, 2011; Received in revised form account for the individual smell that characterizes a given sub-
February 17, 2011; Accepted for publication February 20, 2011. ject, transient components can impart fluctuations due to the
© 2011 American College of Allergy, Asthma & Immunology.
Published by Elsevier Inc. All rights reserved. dietary regimen and other ambient influences, and still others
doi:10.1016/j.anai.2011.02.016 can be associated with pathologic metabolisms specific to dif-

VOLUME 106, JUNE, 2011 451

ferent disease states. The complex matrix of exhaled breath blow into an in-car breathalyzer before starting the ignition.
components is referred to as molecular breath signature. The alcohol interlock can be set at different levels and limits.
For many years physicians have been “sniffing” for spe- Other interesting developments related to systemic bio-
cific odors in the air their patients exhale, hence the adjec- markers in exhaled breath are the attempts to directly assess
tives uremic, hepatic, and acetone found in medical texts to gases associated with human morbidity, such as ammonia9
describe exhaled breath in the respective diseases. The limi- and acetone,10 with the latter being used also as a proxy for
tations of this organoleptic approach were that diseases would blood levels of glucose. The directly measured gases, which
be diagnosed at a very advanced stage when the systemic have been intensively investigated as biomarkers in lung
metabolism was totally compromised. Some 4 decades ago morbidity, are nitric oxide (NO) and carbon monoxide.
Linus Pauling demonstrated that minute amounts of multiple
compounds could be detected and quantitatively measured by Nitric Oxide
gas chromatographic analysis of exhaled air and urine va- Gustafsson et al11 were the first to detect NO, a highly
pors.2 Increased levels of some of these compounds are reactive molecule, in the exhaled breath of animals and
indicative of systemic disorders and extrapulmonary organ humans in 1991. Two years later, Alvin et al12 reported an
failures, which could be referred to as systemic biomarkers. increase of NO in the exhaled breath of asthmatic patients,
Since that time technological progress has made it possible to which gave an impetus to research aimed at assessing the
develop miniature instruments capable of measuring ex- usefulness of this and other gases in different clinical situa-
tremely large numbers of chemical analytes with limits of tions. As a result, a much better insight was gained about the
detection within the nanomolar and picomolar range.3 role NO plays in the regulation of the smooth muscle tone of
This marked improvement in the detective power of breath the pulmonary blood vessels and the bronchi. The increase in
analysis has prompted the exploration of airway diseases by NO during inflammation has been demonstrated to be due to
evaluation of biomarkers deriving from the airways and lung activation of inducible NO synthase expressed by epithelial
structures. These can be referred to as lung biomarkers. The cells in response to proinflammatory cytokines and oxi-
rationale for this approach is based on research performed in dants.13 Because expectations were high, several companies
the 1980s and early 1990s, when it was recognized that the engineered devices using the principle of chemiluminescence
substrate of asthma symptoms is inflammation of the mucosa to measure the minimal amounts of NO in the exhaled air (in
and the underlying tissues lining the airways.4 Once the the range of parts per billion), with which many dozens of
immunologic mechanisms of this pathologic process set in studies were conducted, bringing the method to the stage of
motion, the process carries on with fluctuations despite treat- clinical use. The role of different extraneous factors, such as
ment. Still further, while the vicious cycle of allergic inflam- inspiration maneuvers, breath holding, exhalation flow rate,
mation spins, it brings about remodeling of the airways with exhalation time, and oral pressure, with possible bearing on
early impairment and premature death.5 These phenomena exhaled NO (eNO) measurement, has been elucidated.14 Frac-
occur as a result of interplay of multiple cellular and fluid- tional eNO (FeNO) levels were shown to correlate with
phase ingredients. It was obvious that the invasive ap- sputum eosinophil count, airway hyperresponsiveness, bron-
proaches, such as bronchoscopy with bronchoalveolar lavage, chodilator response, serum IgE levels, allergen skin prick
initially used to decipher the nature of asthma would not be testing, asthma symptoms, and lung function.15,16 This led to
applicable in routine clinical practice. The first noninvasive the general belief that atopy is associated with higher levels
method that was validated to assess airway inflammation was
of eNO. However, the analysis of different subgroups of
the examination of induced sputum.6,7 Although sputum anal-
atopic individuals now suggests that it is the active inflam-
ysis is still a method of reference, it could not establish itself
mation in atopic individuals with clinical manifestations of
as a routine standard because it is time-consuming, sophisti-
airway disease, rather than atopy itself, that accounts for the
cated, and expensive. It was tempting to look for biomarkers
of inflammation directly in the exhaled air. increased production of eNO.14 Other patient characteristics,
such as age, height, weight, body mass index, sex, and race,
may affect the measurements to a lesser degree, as well as
EXHALED BREATH ANALYSIS activities such as smoking, alcohol use, spirometric testing,
Directly Determined Components of Exhaled Breath sputum induction, and environmental exposures.17,18 The cur-
Gases appearing in the exhaled breath as by-products of rently available equipment and dedicated software allow ac-
different metabolic pathways or after oral ingestion can be counting for different confounding factors.
detected and quantitated. Thus, ethanol measurement has These ground studies paved the way for standardization of
found wide application in the control of alcohol consumption the method, and subsequently the American Thoracic Society
by drivers. A recent application of interest is the installing of and the European Respiratory Society published recommen-
devices called Alcolocks or alcohol interlock systems in dations for measuring FeNO, as it was officially denoted.19,20
certain types of transportation vehicles in Sweden.8 These are To increase the reproducibility, it was proposed that measure-
automatic control systems that are designed to prevent driv- ments were done in duplicate and a third measurement was to
ing after excessive alcohol intake by requiring the driver to be made if the first two differed by more than 10%.

452 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

 The present applications of NO measurement cover haled breath condensate (EBC), obtained by cooling exhaled
asthma diagnosis, monitoring, management, and treatment air, which contains water vapor and microdroplets. The com-
of asthma.21,22 Thus, the sensitivity of FeNO measurement at position of EBC is believed to reflect that of the airway
levels higher than 20 ppb in patients with symptoms sugges- epithelial lining fluid.37 The microdroplets are the actual
tive of asthma has been shown to be 88%, with a negative carriers of the multitude of VOCs, but little is known about
predictive value of 92%.23 With the appearance of cheaper their formation and detachment from the airway walls during
portable handheld devices based on electrochemical sensing breathing. They are diluted in the resulting EBC between
on the market, the possibility was contemplated to perform 5,000 and 25,000 times.38 The condensation of the water
serial measurements to monitor disease activity and to steer vapors in exhaled breath is achieved by exhalation through
asthma control,24 especially because it was demonstrated that simple cooling devices, making EBC collection totally non-
the increase of FeNO precedes the decrease in peak expira- invasive and consequently particularly easy to perform even
tory flow rates.25 Another lucrative possibility is to titrate the in children with severe disease.39 A technique has been de-
optimal maintenance dose of inhaled steroids.26 Taken to- veloped to safely obtain EBC even from infants using a face
gether, these applications held the promise to use FeNO to mask connected to a cooling device.40 Influences confound-
guide asthma management.27 However, a carefully designed ing the accuracy of the measurements, such as smoking,
study by Szefler and coworkers28 showed that the use of alcohol consumption, equipment, exercise, mode and rate of
FeNO neither improved asthma control nor allowed reduction breathing, nasal and salivary contamination, environmental
in the dose of inhaled glucocorticosteroid.28 temperature and humidity, and the nature of determination
An important advantage of the method is related to the assays used, have been identified.41,42 New techniques for
noninvasive nature and the simplicity of the FeNO measure- diversifying the number of known biomarkers with increased
ment, which makes it applicable in children and even in- detection threshold are already on the way.43 Recommenda-
fants.29,30 The special promise in these youngest patients is tions have been recently published on how to collect EBC in
held by the fact that there are virtually no objective measures an attempt to minimize differences due to sampling devices
to support the diagnosis and control of treatment in those and collection protocols.44
younger than 5 years. Conclusive trials are still awaited to A large number of mediators have been measured in EBC,
clearly demonstrate the benefit of FeNO measurements in the among which few have proven clinically useful. These can be
grouped into biomarkers of oxidative stress, arachidonic acid
clinical setting.31
metabolites, NO-related products, pH of the EBC, cytokines
Carbon Monoxide and chemokines, and proteins. A detailed overview of all the
Another gaseous constituent of exhaled breath is exhaled different components investigated in EBC has been recently
carbon monoxide (eCO), which has been initially suggested published45 (Table 1). Some of these EBC biomarkers corre-
as a measure of oxidative stress.32 Its concentration in the late with asthma severity, lung function impairment, and
exhaled breath derives from endogenous production by dif- airway remodeling, and others hold promise as identifiers of
ferent tissues as a result of haem metabolism catalyzed by specific asthma phenotypes, such as aspirin-sensitive asthma
oxygenase enzymes.33 It plays an important role as modulator and exercise-induced asthma.
of inflammation, cellular apoptosis, proliferation, and differ- Despite the encouraging positive results to date, the intro-
entiation.34 Carbon monoxide in the ambient air, which re- duction of EBC in everyday clinical practice requires the
flects air pollution from burning fossil fuels and tobacco resolution of some methodologic pitfalls, the standardization
smoking, influences its levels in the exhaled breath. It is of EBC collection, and finally the identification of the reli-
measured with simple electrochemical methods by means of able biomarkers that are reproducible, have normal values,
portable devices in the parts per million range. A recent and provide information about the underlying inflammatory
meta-analysis assessing the value of eCO in asthma manage- process and the response to treatment. An important issue to
ment concludes that eCO is elevated in asthmatic patients but be resolved is finding a reliable approach to account for the
that its levels only partially reflect disease severity and con- dilution of the microdroplets by the water vapor in the ex-
trol.35 Because of the confounding effect of tobacco smoking, haled air. Three candidate markers of dilution (urea, total
eCO might be a potentially useful noninvasive biomarker of cations, and conductivity of vacuum-treated EBC) have been
airway inflammation and oxidative stress in nonsmoking introduced, with the assumption that concentrations of each
asthmatic patients. A specifically designed study challenges indicator in the epithelial lining fluid are similar to those in
its utility as one time point measurement but still assumes the plasma.38 Accounting for the level of dilution of the EBC
some benefit in longitudinal follow-up.36 may help our judgment about the usability of certain markers
of inflammation. Thus, measuring conductivity of vacuum-
Indirect Measurements in Exhaled Breath Condensate treated EBC samples to account for dilution resulted in a
Most trace VOCs contained in exhaled breath currently can- disappointing lack of differences between asthmatic patients
not be directly measured because this requires the develop- and healthy controls for the potential candidates for airway
ment of specific sensors with outstanding sensitivity and inflammation biomarkers: adenosine and adenosine triphos-
specificity. New opportunities have opened up by using ex- phate.46 The conclusion was that the relation between EBC

VOLUME 106, JUNE, 2011 453

Table 1. Exhaled Breath Biomarkers Recognized as Meaningful in Asthma Diagnosis and Monitoringa
Nitric oxide–related Arachidonic acid
Oxidative stress biomarkers Others
biomarkers metabolites: eicosanoids

Hydrogen peroxide Nitrite/nitrate Prostanoids: prostaglandins pH

E2, D2, and F2␣ and
thromboxane B2
Isoprostanes (8-isoprostane, 15-F12-IsoP) Nitrotyrosine Leukotriene B4 and cysteinyl Purines: adenosine, adenosine
leukotrienes C4, D4, and E4 triphosphate, adenosine
monophosphate
Aldehydes and thiobarbituric acid–reactive S-Nitrosothiols Epoxides Cytokines: IL-2, -4, -5, -6, -8, -10,
products and -17, TNF-␣, TGF-␤, IFN-␥
Chemokines: CCL-3, 4,
5 (RANTES), 11 (eotaxin),17, 22
Proteins: albumin, C-reactive
protein, endothelin 1, others
Abbreviations: IFN-␥, interferon ␥; IL, interleukin; TGF-␤, transforming growth factor ␤; TNF-␣, tumor necrosis factor ␣.
a
Common features include highly reactive compounds and pronounced biological effects in minimal quantities, which were consistently different
in asthma patients compared with healthy controls and patients with other lung diseases.

mediator concentration and EBC conductivity highlights the Although the first experiments were made in sealed cham-
importance of further standardization of the EBC method and bers with sophisticated equipment requiring extensive train-
the need for more studies to understand airway droplet for- ing of the patients to take the measurements, a specially
mation. Drawbacks of EBC analysis derive from the fact that designed, handheld instrument was built that allowed mea-
the concentrations of mediators in EBC are low, nearing the surements to be taken in regular indoor environments without
detection limit of currently available techniques, so more special requirements from the tested patients. It proved suc-
sensitive methods, such as high-performance liquid chroma- cessful in differentiating asthmatic from nonasthmatic pa-
tography, negative ion chemical ionization mass spectrome- tients and picked the improvement in the condition of patients
try, gas chromatography–mass spectrometry, nuclear mag- treated with inhaled anti-inflammatory drugs52 and outlined
netic resonance– based spectroscopy, and field asymmetric the possibility of using this portable instrument for daily
ion mobility spectrometry, should be considered for this monitoring of airway correlating with parallel peak expira-
assay.43,45 Furthermore, the anatomical sources of the com- tory flow measurements.53 Software improvements would
pounds measured in EBC are not well defined, and most of make the device still friendlier to patients and physicians and
the measurements are not done in real time. would render the time for measurement minimal.54
INTEGRAL ASSESSMENT OF AIRWAY Electronic Nose, Metabolomics, and Phenotyping
INFLAMMATION BY MEANS OF EXHALED The VOC profiles can be assessed using integrative analysis
BREATH by an electronic nose, a device that uses composite nanosen-
Exhaled Breath Temperature sor arrays based on carbon black-polymer composite vapor
The deep structures of the lung typically have temperatures detectors combined with inbuilt electronic learning algo-
representative of the body core. The temperatures are deter- rithms, which can put together exhaled molecular fingerprints
mined by the blood flowing along the rich vascular network (breath prints). These recognition patterns can differentiate be-
of the alveoli. The temperature of the inhaled air is tempered tween different disease states.55,56 Of particular interest are the
during its flow in and out of the branching airways, which studies demonstrating the ability of the electronic nose to dif-
have a separate system of blood supply. Because blood is the ferentiate between asthmatic patients and healthy controls and
main carrier of thermal energy maintaining the core body between asthma and chronic obstructive pulmonary disease pa-
temperature, processes that would modify its flow within the tients.57,58 A commercial device is now available, which is cur-
airway walls might reflect on the exhaled breath temperature. rently tested in different disease states. A different approach
Several research teams have investigated the assumption that using DNA-coated sensors has also been reported.59
inflammation of the airways would influence the temperature Metabolomics is another emerging field of integral as-
of the air coming from the alveoli of the lungs and that this sessment of exhaled breath components, so far using only
added signal could be picked by appropriate means.47-49 In EBC. The concept has been coined by Nicholson as sys-
previous experiments it was demonstrated that in asthmatic tematic study of the unique chemical fingerprints that
adults and children there was correlation between the tem- specific cellular processes leave behind, specifically of
perature of the exhaled breath and the bronchial blood flow, their small-molecule metabolite profiles.60 This approach
the FeNO levels, and the number of sputum eosinophils.50,51 requires identification of a huge multiplicity of metabolitic

454 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY

products characterizing different disease states. It has been 4. WHO/NHLBI Workshop Report. Global Strategy for Asthma Manage-
proven applicable to EBC, but there is a way to go until it ment and Prevention. Bethesda, MD: National Institutes of Health,
National Heart, Lung, and Blood Institute; 1995. Publication 95-3659.
reaches clinical validity.61 5. Davies DE, Wicks J, Powell RM, Puddicombe SM, Holgate ST. Airway
The discussed integral approaches come in time with remodeling in asthma: new insights. J Allergy Clin Immunol. 2003;111:
the advancement of electronic technologies, which make pos- 215–225.
sible processing huge amounts of data. This could enhance 6. Popov TA, Gottschalk R, Kolendowicz R, Dolovich J, Powers P, Har-
greave FE. The evaluation of a cell dispersion method of sputum
the efforts to identify disease phenotypes, which parcel a examination. Clin Exp Allergy. 1994; 24: 778 –783.
disease entity into subgroups with common characteristics 7. Popov TA, Pizzichini MMM, Pizzichini E, et al. Some technical factors
that may affect management. Thus, the common disorder influencing the induction of sputum for cell analysis. Eur Respir J.
asthma is probably a collection of different phenotypes rather 1995;8:559 –565.
than a single disease.62 In the future, more specific biomark- 8. Hök B, Pettersson H, Andersson AK, Haasl S, Åkerlund P. Breath
analyzer for alcolocks and screening devices. IEEE Sensors J. 2010;10:
ers would certainly be needed to discriminate among different 10 –15.
asthma phenotypes and guide individual treatments. 9. Gouma P, Kalyanasundaram K, Yun X, Stanacevic M, Wang L. Nano-
sensor and breath analyzer for ammonia detection in exhaled human
DISCUSSION breath. IEEE Sensors J. 2010;10:49 –53.
The present overview encompasses a broad range of tech- 10. Saraoglu HM, Koçan M. Determination of blood glucose level-based
niques used to assess different aspects of human exhaled breath analysis by a quartz crystal microbalance sensor array. IEEE
Sensors J. 2010;10:104 –109.
breath, some of which are at the proof-of-concept stage of 11. Gustafsson LE, Leone AM, Persson MG, Wiklund NP, Moncada S.
development, whereas others have applied for research or Endogenous nitric oxide is present in the exhaled air of rabbits, Guiney
clinical judgment. The more than 15-year-old saga of FeNO pigs, and humans. Biochem Biophys Res Commun. 1991;181:852– 857.
measurement is a typical example of the extensive route that 12. Alving K, Weitzberg E, Lundberg JM. Increased amount of nitric oxide
in exhaled air of asthmatics. Eur Respir J. 1993;9:1368 –1370.
needs to be covered. With more than 2,000 publications in 13. Eiserich JP, Patel RP, O’Donnell VB. Pathophysiology of nitric oxide
PubMed on the topic, there are still controversies about its and related species: free radical reactions and modification of biomol-
utility, reflected by the fact that the most recent Global ecules. Mol Aspects Med. 1998;19:221–357.
Initiative for Asthma guidelines do not recommend its use for 14. Alving K, Malinovschi A. Basic aspects of exhaled nitric oxide: exhaled
guiding treatment.63 Recently, a well-defined track has been biomarkers. Eur Respir Monograph. 2010;49:1–31.
15. Covar RA, Szefler SJ, Martin RJ, et al. Relations between exhaled nitric
suggested in proving that a biomarker is apt for use in routine oxide and measures of disease activity among children with mild-to-
practice: the Standards for Reporting of Diagnostic Accuracy moderate asthma. J Pediatr. 2003;142:469 – 475.
initiative.64 These standards outline all particulars that need to 16. Kovesi T, Kulka R, Dales R. Exhaled nitric oxide concentration is
be assembled until a specific biomarker reaches maturity: its affected by age, height, and race in healthy 9- to 12-year-old children.
definition and biological role, the characteristics of the study Chest. 2008;133:169 –175.
17. Dressel H, de la Motte D, Reichert J, et al. Exhaled nitric oxide:
populations and the control groups in light of the target independent effects of atopy, smoking, respiratory tract infection, gender
disease, technical details about the methods and equipment and height. Respir Med. 2008;102:962–969.
used, the data collection process and the statistical analysis, 18. Komakula S, Khatri S, Mermis J, et al. Body mass index is associated
and the inferences about the clinical applicability. with reduced exhaled nitric oxide and higher exhaled 8-isoprostanes in
asthmatics. Respir Res. 2007;8:32– 41.
CONCLUSION 19. Kharitonov S, Alving K, Barnes PJ; The European Respiratory Society
Task Force. Exhaled and nasal nitric oxide measurements: recommen-
Identifying biomarkers in exhaled breath, directly in the out- dations. Eur Respir J. 1997;10:1683–1693.
flowing air or in EBC, is a lucrative approach that would help 20. ATS/ERS recommendations for standardized procedures for the online
the diagnosis, monitoring, management, and treatment of and offline measurement of exhaled lower respiratory nitric oxide and
systemic and lung diseases. There are 2 different but com- nasal nitric oxide, 2005. Am J Respir Crit Care Med. 2005;171:912–930.
21. Kharitonov SA, Barnes PJ. Exhaled biomarkers. Chest. 2006;130:
plementary trends: the creation of technology or the use of 1541–1546.
integral approaches to examine exhaled breath. Thus, the 22. Murugan A, Prys-Picard C, Calhoun WJ. Biomarkers in asthma. Curr
emphasis on asthma management will gradually shift from Opinion Pulm Med. 2009;15:12–18.
judgments made on the basis of subjective symptoms and 23. Smith AD, Cowan JO, Filsell S, et al. Diagnosing asthma: comparisons
objective lung function measurements to noninvasive evalu- between exhaled nitric oxide measurements and conventional tests. Am
J Respir Crit Care Med. 2004;169:473– 478.
ation of the type and level of airway inflammation. 24. Pijnenburg MW, Hofhuis W, Hop WC, De Jongste JC. Exhaled nitric
oxide predicts asthma relapse in children with clinical asthma remission.
REFERENCES Thorax. 2005;60:215–218.
1. Davis CE, Frank M, Mizaikoff B, Oser H. The future of sensors and 25. Harkins MS, Fiato KL, Iwamoto GK. Exhaled nitric oxide predicts
instrumentation for human breath analysis. IEEE Sensors J. 2010;10: asthma exacerbation. J Asthma. 2004;41:471– 476.
3– 6. 26. Pijnenburg MW, Bakker EM, Hop WC, De Jongste JC. Titrating steroids
2. Pauling L, Robinson AB, Teranishi R, Cary P. Quantitative analysis of on exhaled nitric oxide in children with asthma: a randomized controlled
urine vapor and breath by gas-liquid partition chromatography. Proc trial. Am J Respir Crit Care Med. 2005;172:831– 836.
Natl Acad Sci U S A. 1971;68:2374 –2376. 27. Taylor DR. Nitric oxide as a clinical guide for asthma management. J
3. Davis CE, Bogan MJ, Sankaran S, et al. Analysis of volatile and Allergy Clin Immunol. 2006;117:259 –262.
non-volatile biomarkers in human breath using differential mobility 28. Szefler SJ, Mitchell H, Sorkness CA, , et al. Management of asthma
spectrometry (DMS). IEEE Sensors J. 2010;10:114 –123. based on exhaled nitric oxide in addition to guideline-based treatment

VOLUME 106, JUNE, 2011 455

 for inner-city adolescents and young adults: a randomised controlled 48. Piacentini GL, Bodini A, Zerman L, et al. Relationship between exhaled
trial. Lancet. 2008;372:1065–1072. air temperature and exhaled nitric oxide in childhood asthma. Eur Respir
29. Baraldi E, Carraro S. Exhaled NO and breath condensate. Paediatr J. 2002;20:108 –111.
Respir Rev. 2006;7(suppl 1):S20 –S22. 49. Popov TA, Kralimarkova TZ, Tzachev CT, Dunev S, Dimitrov VD, Gill
30. Gogate S, Katial R. Pediatric biomarkers in asthma: eosinophils and J. Development of an individual device for exhaled breath temperature
leukotriene. Curr Opin Allergy Clin Immunol. 2008;8:154 –157. measurement. IEEE Sensors J. 2010;10:110 –113.
31. Oetsky HL, Cates CJ, Li A, et al. Tailored interventions based on 50. Paredi P, Kharitonov SA, Barnes PJ. Correlation of exhaled breath
exhaled nitric oxide versus clinical symptoms for asthma in children and temperature with bronchial blood flow in asthma. Respir Res. 2005;6:
adults. Cochrane Database Syst Rev. 2009;4:CD006340. 1–10.
32. Horvath I, Donnelly LE, Kiss A, Paredi P, Kharitonov SA, Barnes PJ. 51. Piacentini G, Peroni D, Crestani E, et al. Exhaled air temperature in
Raised levels of exhaled carbon monoxide are associated with an in- asthma: methods and relationship with markers of disease. Clin Exp
creased expression of heme oxygenase-1 in airway macrophages in Allergy. 2007;37:415– 419.
asthma: a new marker of oxidative stress. Thorax. 1998;53:668 – 672. 52. Popov TA, Dunev SS, Kralimarkova TK, Kraeva S, DuBuske LM.
33. Ryter SW, Choi AM. Heme oxygenase-1/carbonmonoxide: from metab- Evaluation of a simple, potentially individual device for exhaled breath
olism to molecular therapy. Am J Respir Cell Mol Biol. 2009;41: temperature measurement. Respir Med. 2007;101:2044 –2050.
251–260. 53. Popov TA, Kralimarkova TZ, Lazarova C, Tzachev CT, Dimitrov VD.
34. Dolinay T, Choi AM, Ryter SW. Exhaled carbon monoxide: mecha- Daily monitoring of asthmatics by means of individual devices for
nisms and clinical applications. Exhaled Biomarkers. Eur Respir Mono- exhaled breath. IEEE Sensors J. 2010;10:44 – 48.
graph. 2010;49:82–93. 54. Popov TA, Kralimarkova TZ, Tzachev CT, Dimitrov VD, Mun KK, Gill
35. Zhang J, Yao X, Yu R, et al. Exhaled carbon monoxide in asthmatics: a J. Exhaled breath temperature measurement made easy. Pediatr Allergy
Immunol. 2009;20:200 –201.
meta-analysis. Respir Res. 2010;11:50.
55. Lewis NS. Comparison of mammalian and artificial olfaction based on
36. Pearson P, Lewis S, Britton J, Fogarty A. Exhaled carbon monoxide
arrays of carbon black-polymer composite vapor detectors. Acc Chem
levels in atopic asthma: a longitudinal study. Respir Med. 2005;99:
Res. 2004;37:663– 672.
1292–1296.
56. Thaler ER, Hanson CW. Medical applications of electronic nose tech-
37. Hunt J. Exhaled breath condensate: an evolving tool for noninvasive
nology. Expert Rev Med Devices. 2005;2:559 –566.
evaluation of lung disease. J Allergy Clin Immunol. 2002;110:28 –34. 57. Dragonieri S, Schot R, Mertens BJ, et al. An electronic nose in the
38. Effros RM. Exhaled breath condensate: delusion or dilution? Chest. discrimination of patients with asthma and controls. J Allergy Clin
2010;138:471– 472. Immunol. 2007;120:856 – 862.
39. Baraldi E, Ghiro L, Piovan V, Carraro S, Zacchello F, Zanconato S. 58. Fens N, Zwinderman AH, van der Schee MP, et al. Exhaled breath
Safety and success of exhaled breath condensate collection in asthma. profiling enables discrimination of chronic obstructive pulmonary dis-
Arch Dis Child. 2003;88:358 –360. ease and asthma. Am J Respir Crit Care Med. 2009;180:1076 –1082.
40. Moeller A, Franklin P, Hall G, Horak F Jr, Wildhaber J, Stick S. 59. Johnson ATC, Khamis SM, Preti G, Kwak J, Gelperin A. DNA-coated
Measuring exhaled breath condensates in infants. Pediatr Pulmonol. nanosensors for breath analysis. IEEE Sensors J. 2010;10:159 –166.
2006;41:184 –187. 60. Nicholson JK, Lindon JC, Holmes E. “Metabonomics”: understanding
41. Kullmann T, Barta I, Antus B, Valyon M, Horváth I. Environmental the metabolic responses of living systems to pathophysiological stimuli
temperature and relative humidity influence exhaled breath condensate via multivariate statistical analysis of biological NMR spectroscopic
pH. Eur Respir J. 2008;31:474 – 475. data. Xenobiotica. 1999;11:1181–1189.
42. Czebe K, Barta I, Antus B, Valyon M, Horváth I, Kullmann T. Influence 61. Carraro S, Rezzi S, Reniero F, et al. Metabolomics applied to exhaled
of condensing equipment and temperature on exhaled breath condensate breath condensate in childhood asthma. Am J Respir Crit Care Med.
pH, total protein and leukotriene concentrations. Respir Med. 2008;102: 2007;175:986 –990.
720 –725. 62. Laenzel SE. Asthma: defining of the persistent adult phenotypes. Lancet.
43. Nording ML, Yang J, Hegedus CM, et al. Endogenous levels of five 2006;368:804 – 811.
fatty acid metabolites in exhaled breath condensate to monitor asthma by 63. Global Initiative for Asthma. GINA report: global strategy for asthma.
high-performance liquid chromatography: electrospray tandem mass www.ginasthma.com. Accessed March 17, 2011.
spectrometry. IEEE Sensors J. 2010;10:123–130. 64. Bossuit PM, Reitsma JB, Bruns DE, et al. The STARD statement for
44. ATS/ERS Task Force on Exhaled Breath Condensate. Exhaled breath reporting studies of diagnostic accuracy: explanation and elaboration.
condensate: methodological recommendations and unresolved ques- Ann Intern Med. 2003;138:W1–W12.
tions. Eur Respir J. 2005;26:523–548.
45. Horvath I, de Jongste JC. Exhaled biomarkers. Eur Respir Monograph.
Requests for reprints should be addressed to:
2010;49:152–230.
Todor A. Popov, MD, PhD
46. Lázár Z, Cervenak L, Orosz M, et al. Adenosine triphosphate concen-
tration of exhaled breath condensate in asthma. Chest. 2010;138: Clinic of Allergy & Asthma
536 –542. Alexander’s University Hospital
47. Paredi P, Kharitonov SA, Barnes PJ. Faster rise of EBT in asthma: a 1 St. Georgi Sofiyski St
novel marker of airway inflammation? Am J Respir Crit Care Med. BG-1431 Sofia, Bulgaria
2002;165:181–184. E-mail: ted.popov@gmail.com

456 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY