Literature Review: Exhaled-Breath Volatile Organic Compound Detection

As SARS COV-2 Biomarker Using Electronic Noses

Parmitasari1, Muhammad Ilyas2

1
Occupational Medicine Specialist Programme, Faculty of Medicine, Universitas Indonesia,
Indonesia
2
Division of Occupational Medicine, Department of Community Medicine, Faculty of
Medicine, Universitas Indonesia, Indonesia
1,2
Jalan Pegangsaan Timur No.16, Menteng, Central Jakarta 10320 Indonesia
Correspondence address: Parmitasari
Email: dr.parmitasari@gmail.com

Abstract
Introduction. Current gold standard for detection of COVID-19 is nasopharyngeal swab
followed with RT-qPCR, which techniques require lengthy procedures and skilful human
resources. Different methods of screening for COVID-19 emerged, including ones that
exploring the potential breath-borne volatile organic compound (VOC) biomarkers. The aim
of this research is to understand how Breath-Borne Volatile Organic Compounds can be used
to detect COVID-19 patients and how dependable this method in daily practice, based on the
evidence-based literature.
Method. The literature searching was performed via electronic databases from PubMed,
Scopus, ScienceDirect, and hand searching method. The keywords used were “SARS CoV-2”,
“coronavirus, sars”, “COVID”, “Volatile Organic Compound”, and “Biomarker”. The
articles were chosen based on the given inclusion and exclusion criteria. Selected articles were
then critically appraised.
Results. Three cross-sectional articles were selected after the screening process and manual
searching. Based on the selected evidence-based literatures, breath-borne volatile organic
compound detection to detect COVID-19 patients shows potential utilization, although the
sensitivity and specificity are still inconsistent. The largest study conducted in effort to
approach the real-life environment setting has 66.7% in sensitivity and 43% in specificity.
Conclusion. Electronic nose works to analyse volatile organic compound pattern in exhaled
breath, called the ‘breath print’, by their reaction to sensors incorporated in the device.
Current studies show that exhaled-breath VOC pattern detection with electronic noses using
metal oxide sensors have various sensitivity and specificity ranging between 66.7% - 100% in
sensitivity, and 43 % - 97.6% in specificity.

Keywords: SARS CoV-2, coronavirus, COVID, volatile organic compound, biomarker.

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Table of Contents
Abstract ...................................................................................................................................... 1
Table of Contents ....................................................................................................................... 2
Introduction ................................................................................................................................ 3
Methods...................................................................................................................................... 3
Results ........................................................................................................................................ 5
Discussion .................................................................................................................................. 6
Conclusion ................................................................................................................................. 6
References .................................................................................................................................. 7

2
Introduction
Current gold standard for detection of COVID-19 is nasopharyngeal swab followed with RT-
qPCR, which techniques require lengthy procedures and skilful human resources.1 Different
methods of screening for COVID-19 emerged, including ones that exploring the potential
breath-borne volatile organic compound (VOC) biomarkers. As the exhaled breath contains
many volatile organic compound (VOCs), it has been investigated and considered as
biomarkers for lung cancer, oxidative stress, and many other diseases.2,3 The aim of this
research is to understand how Breath-Borne Volatile Organic Compounds can be used to detect
COVID-19 patients and how dependable this method in daily practice, based on the evidence-
based literature.
Electronic noses (e-noses) represent a potential, relatively cheap and easy technique for exhaled
volatile compound pattern analysis. These devices are composites of a sensor array and an in-
built processor, and functionally resemble the biological olfactory receptors in the respect that
they are not selective for a single ligand and upon activation by an odor the sensor array gives
a signal pattern. Thus, electronic noses cannot identify individual molecules but are able to
compare molecular patterns and hence could discriminate exhaled gaseous samples based on
their molecular fingerprints. It is why, the exhaled volatile compound pattern is frequently
referred to as ‘breath print’.4

Methods
Literature search was conducted through electronic databases: PubMed, Scopus, and
ScienceDirect using keywords (Table 1), followed by articles selection based on inclusion and
exclusion criteria (Figure 1). The keywords used were “SARS CoV-2”, “coronavirus, sars”,
“COVID”, “Volatile Organic Compound”, and “Biomarker”. The articles were chosen based
on the given inclusion and exclusion criteria. The inclusion criteria were systematic reviews,
cohort studies, cross sectional studies, COVID-19/ SARS CoV-2, volatile organic compound,
and biomarker. Duplicates, non-English, and irrelevant articles to the purpose of this review
were excluded.
Selected articles were then critically appraised based on Centre of Evidence-Based
Medicine, Oxford University, Critical Appraisal for Diagnostic Study.5 The level of evidence
was also determined based on the Center of Evidence-Based Medicine, Oxford University.6

Table 1 Search strategies using electronic databases from PubMed, Scopus and ScienceDirect

Electronic database Search strategy Hit Selected

PubMed ((((SARS CoV-2) OR (coronavirus, sars[MeSH Terms])) OR 4 0
(covid)) AND (((Volatile) AND (organic)) AND
(compound))) AND (biomarker)
Scopus ((((SARS CoV-2) OR (coronavirus, sars[MeSH Terms])) OR 105 1
(covid)) AND (((Volatile) AND (organic)) AND
(compound))) AND (biomarker)
ScienceDirect ((((SARS CoV-2) OR (coronavirus, sars[MeSH Terms])) OR 117 1
(covid)) AND (((Volatile) AND (organic)) AND
(compound))) AND (biomarker)

3
 ‘SARS CoV-2’or ‘coronavirus, sars’ or COVID,
‘Volatile Organic Compound’, and ‘Biomarker’

Pubmed Scopus ScienceDirect

N=4 N = 105 N = 117

Records screened for relevance of title, abstract, and keywords (N=10)

Records screened after Records excluded

Inclusion criteria: duplicates removed • duplicate (N=5)
• systematic review (N=5)
• cohort study
• Cross sectional
study full text excluded articles:
• COVID-19 • Not related with
• VOC electronic noses (N=2)
• Biomarker • Electronic nose using
other sensors that metal
oxide (N=1)

1 full text articles found

from hand searching

3 relevant full- text

articles used for critical
appraisal

Figure 1 Literature Searching Flow Chart

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 Results
From the online search results, 3 articles were found that fit the inclusion and exclusion
criteria. Articles included in the critical appraisal are articles by M. Rodríguez-Aguilar et al.
(2021)7, Wintjens AGWE, et al. (2020)8, and Snitz K, et al. (2021)9, as seen in table 2.
Table 2 List of articles included in critical appraisal

Validity Importancy Applicability

Representative
Study design

Independent

Value (PPV)
Participants

spectrum of

comparison

Sensitivity

Specificity
&blinding

Predictive

Predictive
Reference
standard

Negative
patients
number

Positive
Level of
applied

Value

sufficiently
Articles

replication
Evidence

Methods
describe
6

permit
M. Rodríguez- CS 84 + + ? 100% 97.6% 97.7% 100% + Level 3
Aguilar et al.
(2021)7
Wintjens CS 219 + + + 86% 54% 40% 92% + Level 2
AGWE, et al.
(2020)8
Snitz K, et al. CS 503 + + + 66.7% 43% 6.22 % 95.8% + Level 2
(2021)9
CS = cross-sectional; + = yes, clearly stated in the article; - = No/not done; ? = not clearly stated in the
article.

The study design by M. Rodriguez-Aguilar et al. (2021) was analytical cross-sectional,

with a targeted sampling of positive and negative subjects from RT-qPCR test. Nasopharyngeal
swab and exhaled breath collection, performed by health care workers, were carried out on all
participating subjects. In addition, an environmental control sample was collected to eliminate
possible interferences during sample collection. The predictive model usefulness was tested on
30 open population subjects, with results of 66.7% sensitivity and 96% specificity.7
Study by Wintjens AGWE, et al. (2020) performed between April and June 2020, when
participants were invited for breath analysis during a swab for RT-PCR was collected. If the
RT-PCR resulted negative, the presence of SARS-CoV-2-specifc antibodies was checked to
confirm the negative result. Breath samples were obtained from 219 participants, 57 of which
were COVID-19 positive and 162 COVID-19 negative. The composition of the exhaled breath
differed significantly between COVID-19-positive and negative participants with an area under
the curve (AUC) of 0.74.8
The experiment in the study by Snitz K, et al (2021), was placed in-line at a national
testing station. Where breath sampling and RT-PCR swabbing was conducted on the same day,
several minutes apart, and double blind. Five hundred and three individuals tested, of which 27
SARS CoV-2 positive (5.4%) by RT-PCR. True positive rate means at 66.7% (Std Dev = 2%).
The associated mean false negative rate was 33.3%, and the mean false positive rate was 57%
(Std Dev = 2%), with an area under the curve (AUC) of 0.58.9

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Discussion
Electronic nose or also known as eNose, works to analyze VOC pattern, the ‘breath
print’, in exhaled breath by their reaction to sensors incorporated in the device.4 In the studies
being appraised, all include electronic noses with metal oxide sensors as the index test and
comparing to the ‘gold standard’ diagnostic test to detect COVID-19.
The quality of the studies being appraised were moderately good (level 2)6, as they were
all individual cross-sectional studies and consistently comparing to standard reference.
Unfortunately, the scale of all three studies were limited. Although, the third study has larger
scale which include 503 samples and conducted in uncontrolled environment.
The first two studies obtained results significantly better than the third. Nevertheless,
this first and the second studies were conducted in a controlled environment, and since a
different electronic nose brand were used, another likely explanation is that these groups used
a better device and applied it using better sampling methods.
Although has lower result of sensitivity and specificity compared to the two first
studies, this third study has a leverage of being conducted in effort to approach the real-life
environment setting, where extremely noisy (olfaction-wise) and highly variable environment
of the drive-through testing station present.
Several limitations of the studies do exist, in which the possibilities of several
medications and comorbidities diseases that may alter the VOCs, were not entirely controlled
in the studies. The size of the pilot sample was also limited; therefore, they still need
confirmation with an external validation cohort due to the severity of the disease.
All the 3 studies showed that using an optimized electronic nose may allow effective
real-time diagnosis, as its simplicity, low-cost, short analysis time and non-invasive, could
function as starting points for establishing actions to mitigate transmission. In all, the use of
olfactory technologies in communities having high transmission rates as well as in resource-
limited settings (limited RDT-Antigen and/or RT-PCR), where targeted sampling is not viable,
could represents a practical COVID-19 screening approach capable of promptly identifying
COVID-19 suspect patients and providing useful epidemiological information to guide
community health strategies in the context of COVID-19. Nevertheless, certain notes need to
draw attention to improve the benefit of electronic nose and breath print technologies in
community setting, which include a firm and safe standard operational procedure to health care
workers as well as to participants/ patients.

Conclusion
Electronic nose works to analyse volatile organic compound pattern in exhaled breath,
called the ‘breath print’, by their reaction to sensors incorporated in the device, may have a
potential as a screening tool, applicable only in an area having high transmission rates as well
as in resource-limited settings (limited RDT-Antigen and/or RT-PCR). Current studies, mostly
in small and moderate scale, show that exhaled-breath VOC pattern detection with electronic
noses using metal oxide sensors have various sensitivity and specificity ranging between 66.7%
- 100% in sensitivity, and 43 % - 97.6% in specificity.
A firm and safe standard operational procedure of electronic noses use for health care
workers as well as for participants/ patients need to be established before the electronic noses
can be use in community, or occupational health setting. A controlled environment and
participants conditions for sample taking need to be advised to user of electronic noses. Need
to keep in mind that electronic noses should only be use as a starting point for screening tool
in the context of COVID-19 and should continue to RT-PCR for case confirmation.

6
 Further studies involving various variables that may alter VOCs breath print, such as
medications, comorbidities, and severities of COVID-19 are required. A study using specific
brand of electronic nose on larger scale as external validation cohort for generic electronic nose
with metal oxide sensors technology to distinguish COVID -19 patients will add further
information regarding the reliability of the specific brand.

References
1. Lippi G, Simundic AM, Plebani M. Potential preanalytical and analytical vulnerabilities
in the laboratory diagnosis of coronavirus disease 2019 (COVID-19). Clinical
Chemistry and Laboratory Medicine. 2020;58(7):1070–6.
2. Chen H, Qi X, Ma J, Zhang C, Feng H, Yao M. Breath-borne VOC Biomarkers for
COVID-19. medRxiv. 2020 Jun 24;2020.06.21.20136523.
3. Vasilescu A, Hrinczenko B, Swain GM, Peteu SF. Exhaled breath biomarker sensing.
Biosensors and Bioelectronics. 2021;182(June 2020):113193.
4. Bikov A, Lázár Z, Horvath I. Established methodological issues in electronic nose
research: How far are we from using these instruments in clinical settings of breath
analysis? Journal of Breath Research [Internet]. 2015;9(3):34001. Available from:
http://dx.doi.org/10.1088/1752-7155/9/3/034001
5. Oxford Centre for Evidence Based Medicine (CEBM). Diagnostic Study Appraisal
Worksheet. 2010.
6. OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence
[Internet]. Oxford Centre for Evidence-Based Medicine. 2011 [cited 2021 Aug 25].
Available from: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-
levels-of-evidence
7. Rodríguez-Aguilar M, Díaz de León-Martínez L, Zamora-Mendoza BN, Comas-García
A, Guerra Palomares SE, García-Sepúlveda CA, et al. Comparative analysis of chemical
breath-prints through olfactory technology for the discrimination between SARS-CoV-
2 infected patients and controls. Clinica Chimica Acta. 2021;519:126–32.
8. Wintjens AGWE, Hintzen KFH, Engelen SME, Lubbers T, Savelkoul PHM, Wesseling
G, et al. Applying the electronic nose for pre-operative SARS-CoV-2 screening.
Surgical Endoscopy. 2020;(0123456789).
9. Snitz K, Andelman-Gur M, Pinchover L, Weissgross R, Weissbrod A, Mishor E, et al.
Proof of concept for real-time detection of SARS CoV-2 infection with an electronic
nose. PloS one. 2021;16(6):e0252121.