Transcript What is in your breath Terence H. Risby, PhD Bloomberg School of Public Health Johns Hopkins University July 17, 2006 EnviroHealth Connections Summer Institute 2006

What is in your breath
Terence H. Risby, PhD
Bloomberg School of Public Health
Johns Hopkins University
July 17, 2006
EnviroHealth Connections
Summer Institute 2006
What are the sources of molecules in breath?
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Any molecule that has a measurable vapor pressure can be
found in breath
Breath will contain molecules originating from inspiratory
air (current or historical exposure)
Breath will contain endogenously produced molecules
from normal and abnormal physiology that originate from
tissues or cells throughout the body
Breath will contain molecules that are directly or indirectly
derived from foods and beverages
Composition of breath is an instantaneous product of all
these processes
History of breath analysis
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Water vapor in breath has been used for centuries to
detect presence of life.
Classical medicine has used subjective impressions of
the odors of urine or breath to diagnose disease.
Lavoisier first detected carbon dioxide in breath in
1784.
Earliest modern publications on breath analysis date
from late 1960s early 1970s
Typical concentrations (v/v) of endogenous molecules
found in human breath
%
O2, H2O, CO2
ppm
(CH3)2CO, CO, CH4, H2,
C2H5OH, C6H10S
ppb
HCHO, CH3CHO, C5H10, C5H12
C2H6, C2H4, NO, CS2, H/Cs
CH3OH, C2H5OH, COS, CH3SH
NH3, CH3NH2, (CH3)2S
Normal human breath profile
Biochemical basis of breath molecules
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H2
C2H5OH
H/Cs
CO
NO
C5H12
C2H6
C2H6CO
NH3
CH4
carbohydrate metabolism
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gut bacteria
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lipid peroxidation/metabolism
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heme catabolism
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nitric oxide synthase
lipid peroxidation
lipid peroxidation
decarboxylation of acetoacetate
protein metabolism
carbohydrate metabolism
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CH3CHO
C5H10
CH3OH
CH3NH2
C2H4
C6H10S
CH3SH
CS2
COS
C2H6S
ethanol metabolism
cholesterol biosynthesis
fruit metabolism
protein metabolism
lipid peroxidation
garlic
methionine metabolism
gut bacteria
gut bacteria
methionine metabolism
Method for breath collection or breath sampling
is as important as the method of analysis.
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Breath components will change as a function of breathing
cycle
Breath molecules originate from cells throughout
oral/nasal cavities, the pulmonary system and the entire
body
Breath composition will change with breathing physiology
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Sampling single breath or multiple breaths
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Single breath sampling
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Control flow
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Control mouth pressure monitor pressure
continuously
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Monitor the concentration of carbon dioxide
continuously
Monitoring a single breath in real-time
Critical orifice
CO2 monitor
Monitor
Pressure
monitor
MOUTH
Filter
Profile of restricted breath
Sampling multiple breaths
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Monitor tidal volume of each breath and breathing
frequency
Monitor the concentration of carbon dioxide
continuously, i.e., determine end-tidal and steady
state concentrations of each breath
Monitor mouth pressure continuously
Monitor pulse
Monitor oxygen saturation
Sample multiple breaths
Sampling tidal breathing
CO2 monitor
NRBV
Breath
Pressure meter
Flow meter
Filter
MOUTH
Effects of ventilation on carbon dioxide
Most developed field of breath analysis is based
upon metabolites of diagnostic substrates
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Detection of labeled carbon dioxide (C13 or C14)
• Stable isotope mass or optical spectroscopy
• Detection of radioactivity
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Selectivity based upon the diagnostic substrate and
biological system under investigation
Knowledge of delivery, reaction and clearance rates critical
Breath sampled at defined time after administration of
diagnostic substrate
Use of C13 labeled substrates
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aminopyrine, caffeine, galactose, methacetin or
erythromycin
liver function
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ketoisocaproate or methionine liver mitochondria function
acetate or glycosyl ureides
orocecal transit time
urea
H. pylori infection
triolein
fat malabsorption
glucose
insulin resistance
linoleic acid
fatty acid metabolism
phenylalanine
phenylalanine hydrolase activity
uracil
dihydropyrimidine dehydrogenase activity
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FDA approved breath tests
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Breath hydrogen test for carbohydrate metabolism
Breath nitric oxide test to monitor therapy for asthma
Breath carbon monoxide test for neonate jaundice
Breath test for diagnosis of H. pylori
Breath test for heart transplant rejection
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Breath ethanol for intoxication (law enforcement)
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Oxidative stress status
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Oxidative stress: damage to cells, tissues and organs caused by
reactive oxygen species such as 02, H202, and OH.
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Reactive Oxygen Species (ROS): initiate or exacerbate specific
diseases or dysfunctions, kill and damage cells.
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Role of ROS in disease and normal aging an important and
growing field of biomedical research.
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Oxidative stress can be quantified through breath measurements
of biomarkers ethane, ethylene and pentane.
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Alternatively, the cellular response to oxidant injury can be
studied by inducing cellular antioxidant defenses and monitoring
biomarker carbon monoxide.
Reactive oxygen species (ROS) are involved in:
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diseases of
prematurity
cardiovascular
disease
airway reactivity and
pulmonary diseases
diabetes
liver disease
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cancer
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Alzheimer's, and Parkinson
diseases
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amyotrophic lateral sclerosis
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scleroderma
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infections
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ischemia/reperfusion injuries
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radiation damage
Chronic oxidant injury in humans
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Chronic liver or kidney disease
Smoking
Effect of antioxidant vitamins
Feeding studies
Breath ethane to monitor vitamin E therapy
Maternal cigarette smoking
ethane pmol/kg.min
4
3
2
1
0
smokers
non-smokers
ethane pmol/kg.min
Neonates of mothers that smoke
175
150
125
100
75
50
25
0
smokers
(FF)
smokers
(BF)
nonsmokers
(FF)
nonsmokers
(BF)
Diet (%)
B
C
A
Fat
37
37
27
saturated
monounsaturated
polyunsaturated
16
13
8
16
13
8
6
13
8
Carbohydrate
Protein
Cholesterol
Fruits/Vegs
48
15
300 mg
100 g/day
48
15
300mg
500 g/day
48
15
300mg
500 g/day
Study design
A
B
three weeks
eight weeks
eight weeks
B
eight weeks
C
X
Baseline
sampling
X
End of study
sampling
Change in breath ethane from baseline to end of study
Diet B
+1.5 ppb
CHANGE
IN
B R E AT H
ETHANE
0.0 ppb
-1.5 ppb
Diet A
Diet C
Oxidative stress and diet restriction
24 month Fisher 344 female rats
ad lib 289.7±10.5 g
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DR 168.4±1.9 g
ad lib
DR
2.31 ± 0.78 pmol/ 100 g min p < 0.5
2.32 ± 0.65 pmol/ 100 g min
ad lib
DR
135 ± 26 pmol / ml CO2 p < 0.0003
97 ± 16 pmol / ml CO2
Effect of exercise on exhaled breath
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Controlled bicycle exercise
 different work loads
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Ventilation monitored continuously
 MV, O2, CO2, Anaerobic threshold
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Cardiac function monitored continuously
 CO, HR, Stroke volumes, Peak filling & emptying rates
Cardiac output and minute ventilation
as a function of exercise
70
60
50
40
30
20
10
0
0
50
100
124
Ethane pmol/ml CO2
Breath ethane as a function of exercise
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
0
24
50
74
100
Exercise (W/S)
124
150
Acetone pmol/ml
CO2
Breath acetone as a function of exercise
1.2
1
0.8
0.6
0.4
0.2
0
0
24
50
74
100
Exercise (W/S)
124
150
Biomarkers of exposure
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chlorinated hydrocarbons
benzene
JP-8
Anesthesia
Warfield Air National Guard Protocol
• Goal: To quantify individual exposure to JP-8 and correlate JP-8 exposure with
adverse health effects
• Requirements:
– Provide a breath sample before work (pre)
– Provide a breath sample after work (post)
• Breath biomarkers quantified in breath were
hydrocarbons, CO, NO, and total sulfur compounds
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Provide a blood sample after work
Provide a urine sample after work
Take a computerized neurocognitive test
Complete and return a questionnaire
Categorization of Subjects
63 Volunteers
Task
Performed
13 crew chiefs (CC)
6 fuel cell workers (FC)
6 fuel specialists (FS)
10 mechanics (ME)
28 incidental workers (IN)
Smoking
Status
17 smokers
46 nonsmokers
Aircrafts at Warfield
A10
C130
Crew Chiefs
Photograph by Pliel
Duties: Perform pre- and post-flight routine inspections
Engine startup times around 15-30 minutes
Typically 2 takeoffs each day
Fuel Cell Workers
Duties: Pull foam in hangar
3 personnel switching tasks
Safety equipment: respirator, boots,
cotton coveralls,
and gloves
Fuel Specialists
Duties: Receive JP-8 on base
Check JP-8 for contaminants and additive concentrations
Refuel aircrafts on the flight line
Safety Equipment worn: gloves
Pre- and 4 hr post occupational
exposure to JP-8
Did Total JP-8 Exposure Increase during the day?
Post Total JP-8 Comparison by Duty
Pre Total JP-8 Comparison by Duty
14
8
12
6
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CC
FC
FS
10
8
[JP-8]
(mg/m3)
[JP-8]
(mg/m3)
4
6
4
2
2
0
0
CC
FC
FS
ME
IN
Duty
Duty
ME
IN
Route of Exposure to JP-8
Post JP-8 Nonvolatiles Comparison by Duty
Post JP-8 Volatiles Comparison by Duty
2
12
*
*
*
FS
ME
10
8
1
[JP-8]
(mg/m3)
6
[JP-8]
(mg/m3)
4
0
2
0
CC
FC
FS
ME
IN
CC
FC
Duty
Duty
Data
IN
Health Effects Associated
with JP-8 Exposure at Warfield AGB
• No correlations with liver or renal effects
• Air National Guard individuals performed poorer
on 20 of the 42 outcomes
– The majority of decreased performances
occurred on response time measurements
– Performed worse on 3 out of 5 multitasking
exercises
How does Exposure Compare Among Military
Bases?
Total JP-8 Base Comparison
100
80
60
[JP-8]
(mg/m3)
40
20
0
Air
Force
Exposed
Air
National
Guard
Exposed
Air
Force
Incidental
Air
National
Guard
Incidental
Exposure to anesthetics in PACU
Question
Can exposure of nurses in recovery
room to anesthesia be estimated from
exhaled breath?
Isoflurane in exhaled breath on Friday
Isoflurane in exhaled breath on Monday
Changes in occlusion pressure
Summary of breath analysis
• Modern breath analysis has a history of more than 35
years
• Breath analysis is non-invasive
• Breath can be easily collected in field, clinic, in-patient,
OR and ICU
• Breath can be collected from neonate to the elderly
(mouse to horse)
• Breath can be collected multiple times without risk to
patient
• Children give breath samples willingly
• Many modern analytical methods have sufficient
sensitivity to detect breath molecules
Exciting new directions for breath analysis
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Portable hand held, real time breath monitors using:- quantum
cascade lasers in the infra red; mini mass specs; mini GCs; etc
Breath profiling
New diagnostic substrates with different selectivities:identifying genetic abnormalities
Diagnoses in field or developing countries :- where maintaining
blood samples can be difficult
Diagnoses in neonatal intensive care unit:- easier to get breath
than blood or urine
Using breath to determine exposure to pollutants
Breath condensate
Collaborators
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Study Subjects: Patients, Nurses, Air Force & Air Guard Personnel
Former students: Cope, Tu, Sehnert, Long, Kazui, Andreoni, Fleischer, Solga
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Pediatrics: Schwarz, Marban
Surgery: Bulkley, Burdick, Cameron
Cardiology: Lowenstein, Gerstenblith
Anesthesiology: Brown, Merrit, Nyham
Pulmonary Medicine: Orens, Studer
Oncology: Yung, Abrams
Hepatology: Diehl, Solga
Weight loss, exercise: Cheskin, Gerstenblith
Cognitive Studies: Kay
Aging: NIA
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Support NIH, USAFOSR
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