Exhaled breath condensate (EBC) as a matrix for nanoparticle exposure and health effect evaluation : final scientific report

The aim of this pilot project was to evaluate the feasibility of assessing the deposited particle dose in the lungs by applying the dynamic light scattering-based methodology in exhaled breath condensateur (EBC). In parallel, we developed and validated two analytical methods allowing the determination of inflammatory (hydrogen peroxide - H2O2) and lipoperoxidation (malondialdehyde - MDA) biomarkers in exhaled breath condensate. Finally, these methods were used to assess the particle dose and consecutive inflammatory effect in healthy nonsmoker subjects exposed to environmental tobacco smoke in controlled situations was done.

Exhaled breath condensate as a matrix for combustion-based nanoparticle exposure and health effect evaluation

Health assessment and medical surveillance of workers exposed to combustion nanoparticles are challenging. The aim was to evaluate the feasibility of using exhaled breath condensate (EBC) from healthy volunteers for (1) assessing the lung deposited dose of combustion nanoparticles and (2) determining the resulting oxidative stress by measuring hydrogen peroxide (H2O2) and malondialdehyde (MDA). Methods: Fifteen healthy nonsmoker volunteers were exposed to three different levels of sidestream cigarette smoke under controlled conditions. EBC was repeatedly collected before, during, and 1 and 2 hr after exposure. Exposure variables were measured by direct reading instruments and by active sampling. The different EBC samples were analyzed for particle number concentration (light-scattering-based method) and for selected compounds considered oxidative stress markers. Results: Subjects were exposed to an average airborne concentration up to 4.3×10(5) particles/cm(3) (average geometric size ∼60-80 nm). Up to 10×10(8) particles/mL could be measured in the collected EBC with a broad size distribution (50(th) percentile ∼160 nm), but these biological concentrations were not related to the exposure level of cigarette smoke particles. Although H2O2 and MDA concentrations in EBC increased during exposure, only H2O2 showed a transient normalization 1 hr after exposure and increased afterward. In contrast, MDA levels stayed elevated during the 2 hr post exposure. Conclusions: The use of diffusion light scattering for particle counting proved to be sufficiently sensitive to detect objects in EBC, but lacked the specificity for carbonaceous tobacco smoke particles. Our results suggest two phases of oxidation markers in EBC: first, the initial deposition of particles and gases in the lung lining liquid, and later the start of oxidative stress with associated cell membrane damage. Future studies should extend the follow-up time and should remove gases or particles from the air to allow differentiation between the different sources of H2O2 and MDA.

Nitric Oxide in the Exhaled Breath Condensate of Healthy Volunteers Collected With a Reusable Device

Background: The analysis of exhaled breath condensate (EBC) is a non-invasive technique that enables the determination of several volatile and nonvolatile substances produced in the respiratory tract, whose measurement may be useful for the diagnosis and monitoring of several respiratory diseases. Objective: The aim of this study was to produce a low-cost reusable device in order to sample exhaled breath condensate in healthy adult volunteers, and to determine the concentration of nitric oxide in the sample collected. Material and methods: The apparatus was made with a U-shaped tube of borosilicate glass. The tube was placed in a container with ice, and unidirectional respiratory valves were fitted to the distal end. Afterwards, nitric oxide was measured in the exhaled breath condensate (EBC) by chemiluminescence. Results: The total cost of the device was $120.20. EBC samples were obtained from 116 volunteers of both sexes, aged between 20 and 70. The mean volume of exhaled breath condensate collected during 10 minutes was 1.0 +/- 0.6 mL, and the mean level of nitric oxide was 12.99 +/- 14.38 mu M (median 8.72 mu M). There was no correlation between the nitric oxide levels in the exhaled breath condensate and age or gender. Conclusion: We demonstrate that it is possible to fabricate a low-cost, efficient, reusable device in order to collect and determine nitric oxide levels in EBC. We have identified no correlation between the nitric oxide levels present in the EBC obtained with this method with either age or sex. (C) 2011 SEPAR. Published by Elsevier Espana, S.L. All rights reserved.

Detection of erythropoietin in exhaled breath condensate of nonhypoxic subjects using a multiplex bead array

As a noninvasive method, exhaled breath condensate (EBC) has gained importance to improve monitoring of lung diseases and to detect biomarkers. The aim of the study was to investigate, whether erythropoietin (EPO) is detectable in EBC. EBC was collected from 22 consecutive patients as well as from healthy individuals. Using a multiplex fluorescent bead immunoassay, we detected EPO in EBC, as well as tumour necrosis factor-alpha (TNF-alpha) in 13 out of 22 patients simultaneously (EPO 0.21 +/- 0.03 in U/mL and TNF-alpha 34.6 +/- 4.2 in pg/mL, mean +/- SEM). No significant differences for EPO levels or correlation between EPO and TNF-alpha were found but TNF-alpha was significantly higher in patients with chronic obstructive pulmonary disease (COPD) than in non-COPD (obstructive sleep apnoea, OSA, and lung healthy patients). This is the first report of detection of EPO in EBC. Due to the small study size more data is needed to clarify the role of EPO in EBC.

8-Isoprostane in nasally exhaled breath condensate in different pediatric lung diseases

OBJECTIVE: Increased levels of 8-isoprostane were found in various human lung diseases suggesting 8-isoprostane as a marker of pulmonary oxidative stress in vivo. The exact role in pediatric lung diseases has not been defined yet. The goal of this study was to clarify the role of 8-isoprostane in nasally exhaled breath condensate as possible marker of oxidative stress in children with different lung diseases. METHODS: Levels of 8-isoprostane were measured in nasally exhaled breath condensate of 29 cystic fibrosis patients, 19 children with a history of wheezing episodes, 8 infants with acute respiratory tract infection and 53 healthy subjects using a specific enzyme immunoassay. RESULTS: Levels of 8-isoprostane did neither discriminate between different disease groups nor correlate with lung function in cystic fibrosis patients. CONCLUSIONS: Levels of 8-isoprostane in nasally exhaled breath condensate do not reflect oxidative stress in children with different lung diseases.

Detection of pulmonary amylase activity in exhaled breath condensate

Amylase activity in exhaled breath condensate (EBC) is usually interpreted as an indication of oropharyngeal contamination despite the fact that amylase can be found in pulmonary excretions. The aim of this study was to recruit and refine an amylase assay in order to detect amylase activity in any EBC sample and to develop a method to identify EBC samples containing amylase of pulmonary origin. EBC was collected from 40 volunteers with an EcoScreen condenser. Amylase assays and methods to discriminate between oropharyngeal and pulmonary proteins were tested and developed using matched EBC and saliva samples. Our refined 2-chloro-4-nitrophenyl-α-D-maltotriosid (CNP-G3) assay was 40-fold more sensitive than the most sensitive commercial assay and allowed detection of amylase activity in 30 µl of EBC. We developed a dot-blot assay which allowed detection of salivary protein in saliva diluted up to 150 000-fold. By plotting amylase activity against staining intensity we identified a few EBC samples with high amylase activity which were aligned with diluted saliva. We believe that EBC samples aligned with diluted saliva contain amylase activity introduced during EBC collection and that all other EBC samples contain amylase activity of pulmonary origin and are basically free of oropharyngeal protein contamination.

Eicosanoids in exhaled breath condensates in the assessment of childhood asthma

The value of measurements of eicosanoids in exhaled breath condensate (EBC) for the evaluation of childhood asthma is still inconclusive most likely because of the limited value of the methods used. In this case-control study in 48 asthmatic and 20 healthy children, we aimed to characterize the baseline profile of the inflammatory mediators cysteinyl leukotrienes (cysLTs), 9(alpha)11(beta)PGF(2), PGE(2), PGF(2alpha), 8-isoprostane (8-iso-PGF(2alpha)) within EBC in asthmatic compared with healthy children using new methods. In addition, we investigated their relation to other inflammatory markers. The assessment included collection of EBC, measurement of fractional exhaled nitric oxide (FE(NO)) and evaluation of urinary excretion of leukotriene E(4.) cysLTs were measured directly in EBC by radioimmunoassay and prostanoids were measured using gas chromatography negative-ion chemical ionization mass spectrometry. Only cysLT levels were significantly higher in asthmatic compared with healthy children (p = 0.002). No significant differences in cysLTs were found between steroid naïve and patients receiving inhaled corticosteroids. In contrast, FE(NO) was significantly higher in steroid naïve compared with steroid-treated asthmatic and healthy children (p = 0.04 and 0.024, respectively). The diagnostic accuracy of cysLTs in EBC for asthma was 73.6% for the whole group and 78.2% for steroid-naïve asthmatic children. The accuracy to classify asthmatic for FE(NO) was poor (62.9%) for the whole group, but improved to 79.9% when only steroid-naïve asthmatic children were taken into consideration. cysLTs in EBC is an inflammatory marker which distinguishes asthmatics, as a whole group, from healthy children.

On-line breath analysis of volatile organic compounds as a method for colorectal cancer detection

Background: Analysis of exhaled volatile organic compounds (VOCs) in breath is an emerging approach for cancer diagnosis, but little is known about its potential use as a biomarker for colorectal cancer (CRC). We investigated whether a combination of VOCs could distinct CRC patients from healthy volunteers. Methods: In a pilot study, we prospectively analyzed breath exhalations of 38 CRC patient and 43 healthy controls all scheduled for colonoscopy, older than 50 in the average-risk category. The samples were ionized and analyzed using a Secondary ElectroSpray Ionization (SESI) coupled with a Time-of-Flight Mass Spectrometer (SESI-MS). After a minimum of 2 hours fasting, volunteers deeply exhaled into the system. Each test requires three soft exhalations and takes less than ten minutes. No breath condensate or collection are required and VOCs masses are detected in real time, also allowing for a spirometric profile to be analyzed along with the VOCs. A new sampling system precludes ambient air from entering the system, so background contamination is reduced by an overall factor of ten. Potential confounding variables from the patient or the environment that could interfere with results were analyzed. Results: 255 VOCs, with masses ranging from 30 to 431 Dalton have been identified in the exhaled breath. Using a classification technique based on the ROC curve for each VOC, a set of 9 biomarkers discriminating the presence of CRC from healthy volunteers was obtained, showing an average recognition rate of 81.94%, a sensitivity of 87.04% and specificity of 76.85%. Conclusions: A combination of cualitative and cuantitative analysis of VOCs in the exhaled breath could be a powerful diagnostic tool for average-risk CRC population. These results should be taken with precaution, as many endogenous or exogenous contaminants could interfere as confounding variables. On-line analysis with SESI-MS is less time-consuming and doesn’t need sample preparation. We are recruiting in a new pilot study including breath cleaning procedures and spirometric analysis incorporated into the postprocessing algorithms, to better control for confounding variables.

Exhaled nitric oxide for monitoring childhood asthma inflammation compared to sputum analysis, serum interleukins and pulmonary function

The level of fractional exhaled nitric oxide (FENO) is significantly elevated in uncontrolled asthma and decreases after anti-inflammatory therapy The aim of this prospective study was to analyze the behavior of FENO in the follow-up and management of the inflammation in asthmatic pediatric patients treated with inhaled corticosteroids (ICS), compared to sputum cellularity, serum interleukins (IL), and pulmonary function. Twenty-six clinically stable asthmatic children aged from 6 to 18 years, previously treated or not with ICS were included. Following an international consensus (GINA), the patients were submitted to standard treatment with inhaled fluticasone for 3 months according to the severity of the disease. During this period, each patient underwent three assessments at intervals of approximately 6 weeks: Each evaluation consisted of the measurement of FENO, determination of serum interleukins IL-5, IL-10, IL-13, and interferon gamma (INF-gamma), spirometry and cytological analysis of spontaneous or induced sputum. A significant reduction in mean FENO and IL-5, without concomitant changes in FEV1, was observed along the study. There was no significant correlation between FeNO and FEV1 in the three assessments. A significant correlation between FeNO and IL-5 levels was only observed in the third assessment (r = 0.499, P=0.025). In most patients, serum IL-10, IL-13, and INF-gamma concentrations were undetectable throughout the study Sputum samples were obtained spontaneously in 11 occasions and in 56 by induction with 3% hypertonic saline solution (success rate: 50.8%), with 39 (69.9%) of them adequate for analysis. Only two of the 26 patients produced adequate samples in the three consecutive evaluations, which impaired the determination of a potential association between sputum cellularity and FeNO levels throughout the study. In conclusion, among the parameters of this study, it was difficult to perform and to interpret the serial analysis of spontaneous or induced sputum. Serum interleukins, which remained at very low or undetectable levels in most patients, were not found to be useful for therapeutic monitoring, except for IL-5 that seems to present some correlation with levels of FeNO exhaled. Monitoring of the mean FEV1 indicated no significant variations during the treatment, demonstrating that functional stability or the absence of obstruction may not reflect the adequate management of asthma. Serial measurement of FeNO seemed to best reflect the progressive anti-inflammatory action of ICS in asthma.

Mecanismos de inflamação brônquica resultantes da exposição a factores ambientais

RESUMO Tratando-se a asma de uma doença respiratória, desde há várias décadas que tem sido abordada a hipótese de que factores ambientais, nomeadamente os relacionados com a qualidade do ar inalado, possam contribuir para o seu agravamento. Para além dos aeroalergenos, outros factores ambientais como a poluição atmosférica estarão associados às doenças respiratórias. O ar respirado contém uma variedade de poluentes atmosféricos, provenientes quer de fontes naturais quer de origem antropogénica, nomeadamente de actividades industriais, domésticas ou das emissões de veículos. Estes poluentes, tradicionalmente considerados como um problema de foro ambiental, têm sido cada vez mais encarados como um problema de saúde pública. Também a qualidade do ar interior, tem sido associada a queixas respiratórias, não só em termos ocupacionais mas também em exposições domésticas. Dentro dos principais poluentes, encontramos a matéria particulada (como as PM10), o O3, NO2, e os compostos orgânicos voláteis (COVs). Se é verdade que os três primeiros têm como principais fontes de exposição a combustão fóssil associada aos veículos automóveis, já os COVs (como o benzeno, tolueno, xileno, etilbenzeno e formaldeído) são poluentes mais característicos do ar interior. Os mecanismos fisiopatológicos subjacentes à agressão dos poluentes do ar não se encontram convenientemente esclarecidos. Pensa-se que após a sua inalação, induzam um grau crescente de stress oxidativo que será responsável pelo desenvolvimento da inflamação das vias aéreas. A progressão do stress oxidativo e da inflamação, associarse- ão posteriormente a lesão local (pulmonar) e sistémica. Neste trabalho pretendeu-se avaliar os efeitos da exposição individual a diversos poluentes, do ar exterior e interior, sobre as vias aéreas, recorrendo a parâmetros funcionais, inflamatórios e do estudo do stress oxidativo. Neste sentido, desenvolveu-se um estudo de painel na cidade de Viseu, em que foram acompanhadas durante 18 meses, 51 crianças com história de sibilância, identificadas pelo questionário do estudo ISAAC. As crianças foram avaliadas em quatro Visitas (quatro medidas repetidas), através de diversos exames, que incluíram execução de espirometria com broncodilatação, medição ambulatória do PEF, medição de FENO e estudo do pH no condensado brônquico do ar exalado. O estudo dos 8-isoprostanos no condensado brônquico foi efectuado somente em duas Visitas, e o do doseamento de malonaldeído urinário somente na última Visita. Para além da avaliação do grau de infestação de ácaros do pó do colchão, para cada criança foi calculado o valor de exposição individual a PM10, O3, NO2, benzeno, tolueno, xileno, etilbenzeno e formaldeído, através de uma complexa metodologia que envolveu técnicas de modelação associadas a medições directas do ar interior (na casa e escola da criança) e do ar exterior. Para a análise de dados foram utilizadas equações de estimação generalizadas com uma matriz de correlação de trabalho uniforme, com excepção do estudo das associações entre poluentes, 8-isoprostanos e malonaldeído. Verificou-se na análise multivariável a existência de uma associação entre o agravamento dos parâmetros espirométricos e a exposição aumentada a PM10, NO2, benzeno, tolueno e etilbenzeno. Foram também encontradas associações entre diminuição do pH do EBC e exposição crescente a PM10, NO2, benzeno e etilbenzeno e associações entre valores aumentados de FENO e exposição a etilbenzeno e tolueno. O benzeno, o tolueno e o etilbenzeno foram associados com maior recurso a broncodilatador nos 6 meses anteriores à Visita e o tolueno com deslocações ao serviço de urgência. Os resultados dos modelos de regressão que incluíram o efeito do poluente ajustado para o grau de infestação de ácaros do pó foram, de uma forma geral, idênticos ao da análise multivariável anterior, com excepção das associações para com o FENO. Nos modelos de exposição com dois poluentes, com o FEV1 como variável resposta, somente o benzeno persistiu com significado estatístico. No modelo com dois poluentes tendo o pH do EBC como variável resposta, somente persistiram as PM10. Os 8-isoprostanos correlacionaram-se com alguns COVs, designadamente etilbenzeno, xileno, tolueno e benzeno. Os valores de malonaldeído urinário não se correlacionaram com os valores de poluentes. Verificou-se no entanto que de uma forma geral, e em particular mais uma vez para os COVs, as crianças mais expostas a poluentes, apresentaram valores superiores de malonaldeído na urina. Verificou-se que os poluentes do ar em geral, e os COVs em particular, se associaram com uma deterioração das vias aéreas. A exposição crescente a poluentes associou-se não só com obstrução brônquica, mas também com FENO aumentado e maior acidez das vias aéreas. A exposição crescente a COVs correlacionou-se com um maior stress oxidativo das vias aéreas (medido pelos 8-isoprostanos). As crianças com exposição superior a COVs apresentaram maiores valores de malonaldeído urinário. Este trabalho sugere uma associação entre exposição a poluentes, inflamação das vias aéreas e stress oxidativo. Vem reforçar o interesse dos poluentes do ar, nomeadamente os associados a ambientes interiores, frequentemente esquecidos e que poderão ser explicativos do agravamento duma criança com sibilância.-----------ABSTRACT: Asthma is a chronic respiratory disease that could be influenced by environmental factors, as allergens and air pollutants. The air breathed contains a diversity of air pollutants, both from natural or anthropogenic sources. Atmospheric pollution, traditionally considered an environmental problem, is nowadays looked as an important public health problem. Indoor air pollutants are also related with respiratory diseases, not only in terms of occupational exposures but also in domestic activities. Particulate matter (such as PM10), O3, NO2 and volatile organic compounds (VOCs) are the main air pollutants. The main source for PM10, O3, NO2 exposure is traffic exhaust while for VOCs (such as benzene, toluene, xylene, ethylbenzene and phormaldehyde) the main sources for exposure are located in indoor environments. The pathophysiologic mechanisms underlying the aggression of air pollutants are not properly understood. It is thought that after inhalation, air pollutants could induce oxidative stress, which would be responsible for airways inflammation. The progression of oxidative stress and airways inflammation, would contribute for the local and systemic effects of the air pollutants. The present study aimed to evaluate the effects of individual exposure to various pollutants over the airways, through lung function tests, inflammatory and oxidative stress biomarkers. In this sense, we developed a panel study in the city of Viseu, that included 51 children with a history of wheezing. Those children that were identified by the ISAAC questionnaire, were followed for 18 months. Children were assessed four times (four repeated measures) through the following tests: spirometry with bronchodilation test, PEF study, FENO evaluation and exhaled breath condensate pH measurement. 8-isoprostane in the exhaled breath condensate were also measured but only in two visits. Urinary malonaldehyde measurement was performed only in the last visit. Besides the assessment of the house dust mite infestation, we calculated for each child the value of individual exposure to a wide range of pollutants: PM10, O3, NO2, benzene, toluene, xylene, ethyl benzene and formaldehyde. This strategy used a complex methodology that included air pollution modelling techniques and direct measurements indoors (homes and schools) and outdoors. Generalized estimating equations with an exchangeable working correlation matrix were used for the analysis of the data. Exceptions were for the study of associations between air pollutants, malonaldehyde and 8-isoprostanes. In the multivariate analysis we found an association between worsening of spirometric outcomes and increased exposure to PM10, NO2, benzene, toluene and ethylbenzene. In the multivariate analysis we found also negative associations between EBC pH and exposure to PM10, NO2, benzene, ethylbenzene and positive associations between FENO and exposure to ethylbenzene and toluene. Benzene, toluene and ethylbenzene were associated with increased use of bronchodilator in the 6 months prior to the visit and toluene with emergency department visits. Results of the regression models that included also the effect of the pollutant adjusted for the degree of infestation to house dust mites, were identical to the previous models. Exceptions were for FENO associations. In the two-pollutant models, with the FEV1 as dependent variable, only benzene persisted with statistical significance. In the two pollutant model with pH of EBC as dependent variable, only PM10 persisted. 8-isoprostanes were well correlated with some VOCs, namely with ethylbenzene, xylene, toluene and benzene. Urinary malonaldehyde did not present any correlation with air pollutants exposure. However, those children more exposed to air pollutants (namely to VOCs), presented higher values of malonaldehyde. It was found that air pollutants in general, and namely VOCs, were associated with deterioration of the airways. The increased exposure to air pollutants was associated not only with airways obstruction, but also with increased FENO and higher acidity of the airways. The increased exposure to VOCs was correlated with increased airways oxidative stress (measured by 8-isoprostane). Children with higher levels of exposure to VOCs had higher values of urinary malonaldehyde. This study suggests a relation between air pollution, airways inflammation and oxidative stress. It suggests also that attention should be dedicated to air quality as air pollutants could cause airways deterioration.

Estimulació beta-adrenèrgica en la síndrome del destret respiratori agut (SDRA)

Estudi elaborat a partir d’una estada al Royal Brompton Hospital, Londres, Regne Unit, durant octubre i novembre del 2006.Els beneficis de la estimulació beta-adrenèrgica en pacients amb lesió pulmonar aguda (LPA) són coneguts, però no es disposa de dades sobre el possible efecte antiinflamatori. El condensat d'aire exhalat (CAE) és una tècnica no-invasiva de recollida de mostres del tracte respiratori inferior, podent ser útil en la monitorització de patologies respiratòries. S’ha usat marcadors biològics en el CAE de pacients ventilats mecànicament amb LPA per estudiar el possible efecte antiinflamatori que el salbutamol hi podria exercir. El CAE va ser recollit abans i després de l'administració de salbutamol inahalat. Inmediatament després es va mesurar la conductivitat i el pH abans i després de la desgasificació amb heli. Es va mesurar la concentració de nitrits i nitrats. Les mostres varen ser liofilitzades i guardades a -80ºC. La concentració de leucotriè B4 es va mesurar després de la reconstitució de la mostra. Els resultats s'expressen com a mitjana (error estàndard de la mostra). No s'han detectat diferències entre els valors de CAE basals dels pacients amb LPA i els de referència de la població sana de Barcelona. Es conclou doncs que el CAE és una tècnica no invasiva que pot ser usada en la monitorització de paceints ventilats mecànicament. El salbutamol inhalat incrementa de manera significativa el pH del CAE dels paceints amb LPA, tot i que un efecte directe de la inhalació de slabutamol no pot ser desestimat.

Pulmonary biomarkers in COPD exacerbations: a systematic review.

Exacerbations of COPD (ECOPD) represent a major burden for patients and health care systems. Innovative sampling techniques have led to the identification of several pulmonary biomarkers. Although some molecules are promising, their usefulness in clinical practice is not yet established. Medline and Highwire databases were used to identify studies evaluating pulmonary sampled biomarkers in ECOPD. We combined 3 terms for ECOPD, 3 for biomarkers and 6 for the sampling method. Seventy-nine studies were considered eligible for inclusion in the review and were analyzed further. Pulmonary biomarkers sampled with non-invasive, semi-invasive and invasive methods were evaluated for their potential to illustrate the disease's clinical course, to correlate to clinical variables and to predict clinical outcomes, ECOPD etiology and response to treatment. According to published data several pulmonary biomarkers assessed in ECOPD have the potential to illustrate the natural history of disease through the modification of their levels. Among the clinically relevant molecules, those that have been studied the most and appear to be promising are spontaneous and induced sputum biomarkers for reflecting clinical severity and symptomatic recovery, as well as for directing towards an etiological diagnosis. Current evidence on the clinical usefulness of exhaled breath condensate and bronchoalveolar lavage biomarkers in ECOPD is limited. In conclusion, pulmonary biomarkers have the potential to provide information on the mechanisms underlying ECOPD, and several correlate with clinical variables and outcomes. However, on the basis of published evidence, no single molecule is adequately validated for wide clinical use. Clinical trials that incorporate biomarkers in decisional algorithms are required.