What is the real utility of breath ammonia concentration measurements in medicine and physiology?

Much effort continues to be devoted to the development of devices to analyse breath ammonia with the anticipation that breath ammonia analyses will be useful in clinical practice. In this perspective we refer to the analytical techniques that have been used to measure breath ammonia, focusing on selected ion flow tube mass spectrometry, SIFT-MS, of which we have special knowledge and understanding. From the collected data obtained using the different techniques, we exam the origins of mouth- and nose-exhaled ammonia and conclude that mouth-exhaled ammonia is always elevated above a concentration that would be equilibrated with blood ammonia and is largely produced by the action of enzymes on salivary urea. Support to this conclusion is given by the reasonable correlation between blood urea concentration and mouth-exhaled ammonia concentration. Further, it is discussed that nose-exhaled ammonia largely originates at the alveolar interface and so its concentration more closely relates to the expected alveolar blood ammonia concentration. Ingestion of proteins results in increased blood/saliva urea and ultimately mouth-exhaled ammonia as does the generation of urease by H. pylori infection. It is also concluded that when mouth-exhaled ammonia is elevated then it may be due to either abnormally high blood urea, a high pH of the saliva/mouth/airways mucosa, poor oral hygiene or a combinations of these.