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Impulse Oscillometry
Interpretation and Practical Applications
Scott Bickel, MD; Jonathan Popler, MD, FCCP; Burton Lesnick, MD, FCCP; and Nemr Eid, MD, FCCP
Simple spirometry and body plethysmography have been routinely used in children aged
. 5 years. New techniques based on physiologic concepts that were first described almost
50 years ago are emerging in research and in clinical practice for measuring pulmonary func-
tion in children. These techniques have led to an increased understanding of the pediatric lung
and respiratory mechanics. Impulse oscillometry (IOS), a simple, noninvasive method using
the forced oscillation technique, requires minimal patient cooperation and is suitable for use
in both children and adults. This method can be used to assess obstruction in the large and
small peripheral airways and has been used to measure bronchodilator response and bron-
choprovocation testing. New data suggest that IOS may be useful in predicting loss of asthma
control in the pediatric population. This article reviews the clinical applications of IOS, with an
emphasis on the pediatric setting, and discusses appropriate coding practices for the clinician.
CHEST 2014; 146(3):841-847
Pulmonary function testing is used to evaluate limited by the child’s ability to follow direc-
respiratory mechanics and physiology in both tions and provide maximal, reproducible
children and adults with suspected respiratory efforts. Some of the challenges in performing
diseases. Spirometry is perhaps the most com- spirometry in younger children, especially
monly used pulmonary function test with the those aged 2 to 5 years, may have led to this
advantage of being readily available in both diagnostic modality being significantly under-
inpatient and outpatient settings, including used.1,2 Current data suggest that only 21% of
many primary care offices. Lung volume mea- primary care practitioners use spirometry in
surement by body plethysmography or gas the diagnosis of asthma in children.3
dilution requires more-expensive equipment
that often requires a dedicated pulmonary Impulse oscillometry (IOS) is an effort-
function testing laboratory. Simple spirometry independent modality based on the well-
and body plethysmography often can be per- described forced oscillation technique4,5
formed successfully in children but may be and has emerged as a method to measure
Manuscript received August 11, 2013; revision accepted January 13, © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
2014. this article is prohibited without written permission from the American
AFFILIATIONS: From the Department of Pediatrics (Drs Bickel and College of Chest Physicians. See online for more details.
Eid), University of Louisville, Louisville, KY, and Georgia Pediatric Pul- DOI: 10.1378/chest.13-1875
monology Associations, PC (Drs Popler and Lesnick), Atlanta, GA.
CORRESPONDENCE TO: Nemr Eid, MD, FCCP, Department of Pediatrics,
University of Louisville, 571 S Floyd St, Ste 414, Louisville, KY 40202;
e-mail: nseid@louisville.edu
journal.publications.chestnet.org 841
pulmonary function in both preschool- and school-aged airways, whereas the reactance is the out-of-phase com-
children in whom reliable spirometry is difficult to ponent of lung impedance and reflects the capacitive
obtain.6 Similarly, adults with both physical and cogni- and inertive properties of the airways. Capacitance can
tive limitations may benefit from this methodology.7 be thought of as reflecting the elasticity of the airway,
This article reviews the clinical use of IOS, potential whereas inertance reflects the mass-inertive forces of the
limitations, and appropriate coding practices for the moving air column.10 Reactance can be viewed as the
clinician. rebound resistance, or an echo, giving information
about the distensible airways.4,10 At low frequencies,
IOS Fundamentals
capacitive pressure loss is large compared with inertive
IOS is a simple, noninvasive method requiring only pas- pressure loss, whereas at higher frequencies, the inertive
sive patient cooperation that allows for the evaluation of properties dominate. Therefore, the reactance at 5 Hz (X5)
lung function through the measurement of both airway reflects the combined effect of tissue elastance and iner-
resistance and airway reactance.1,8 Current IOS proce- tance, although at this lower frequency, the effect of
dures are based on the physiologic concepts of the forced
tissue elastance would dominate. Because the ability of
oscillation technique originally described by Dubois et al4
the lungs to store capacitive energy is primarily manifest
in 1956. IOS uses sound waves to rapidly detect air-
in the small airways, reactance at low frequencies can
way changes and requires only normal tidal breathing
provide important information about the distal airways.
from the patient. Pulmonary mechanics are determined
Although the mathematical model behind resistance
by superimposing small external pressure signals on the
and reactance has been described in detail elsewhere9,11,12
spontaneous breaths of the patient. When analyzed,
and is beyond the scope of this article, it is helpful to
these pressure signals separately quantify the degree of
understand that inertance represents a positive value
obstruction in the central and peripheral airways. Forced
and capacitance a negative value. States that reduce the
oscillation works by having a loudspeaker generate har-
elasticity of the lung, such as fibrosis and hyperinflation,
monic sound waves that flow through a conduit tube and
make capacitance increasingly negative.10
mouthpiece into the respiratory tract of the patient. In
forced oscillometry, these sound waves can be of single The intermediate frequency at which the total reactance
or multiple frequencies, which usually range from is null is known as the resonant frequency (Fres) and is
between 2 and 4 Hz to between 30 and 35 Hz.9,10 IOS is a illustrated by a sample IOS result in Figure 1. The Fres
form of the forced oscillation technique in which the occurs when the magnitudes of the capacitive and
pressure oscillations are applied at a fixed (square wave) inertive pressure loss are the same. This value can be of
frequency of 5 Hz and from which all other frequencies use in discriminating between low-frequency and high-
of interest are derived.8 Pressure and flow transducers frequency reactance values: Below the Fres, the elastic
measure amplitude and phase differences to determine properties of the lung (represented by capacitance)
the impedance of the respiratory system. dominates, whereas above the Fres, inertance domi-
nates.10 The Fres tends to be higher in children, to
The impulses generated by the loudspeaker travel super-
decrease with age, and to be elevated in both restrictive
imposed on normal tidal breathing through the large
and obstructive states.
and small airways, with higher frequencies reflecting
back from the large airways to the mouth and lower The area of reactance (AX) is another common param-
frequencies traveling deeper into the lung before return- eter used in interpreting IOS. AX represents the total
ing. A pressure and flow transducer measures inspiratory reactance (area under the curve) at all frequencies
and expiratory flow and pressure. The resultant signals of between 5 Hz and Fres (Fig 1).10,13 This single value,
pressure and flow are separated from the breathing pat- therefore, comprises all the frequencies measured by
tern by signal filtering. Respiratory impedance is the sum IOS where the elastic properties of the lung (again, rep-
of all the forces (resistance and reactance) opposing the resented by capacitance) dominates over inertance. As
pressure impulses (oscillations) and is calculated from the with X5, this value also provides information regarding
ratio of pressure and flow at each frequency.9,10 peripheral airway obstruction.
Interpreting IOS results requires one to be familiar with The resistance at 5 Hz (R5) represents the total airway
the specific attributes of the test. Resistance is the resistance, and the resistance at 20 Hz (R20) represents
in-phase component of lung impedance and reflects infor- the resistance of the large airways. One can infer the
mation about the forward pressure of the conducting resistance of the small airways by subtracting R20 from
journal.publications.chestnet.org 843
between length of oxygen requirement and a patient’s control and in assisting with clinical decisions and
IOS parameters. treatment plans. Regarding treatment strategies,
Rabinovitch et al55 recently published data correlating
Although studied in other disease states, IOS has per-
elevated AX with positive response to combined long-
haps been best characterized to date for its use in
acting b-agonist therapy vs increasing the dosage of
asthma. Studies have demonstrated that patients with
inhaled corticosteroids, although the exact reasoning
asthma have an elevated R5,39-41 an elevated AX,39,41 an
behind the association remains unclear and further
elevated Fres,39,41 and a more negative X539-41 compared
research is needed. These reports add to existing data
with control subjects. Additionally, improvement in air-
emphasizing the importance of the small airways in
way resistance after bronchodilator administration appears
asthma control.20,22
to correlate well with a bronchodilator response by stan-
dard spirometry.40 When using IOS to assess a patient Clinical applications of IOS may best be illustrated by
with asthma, one should look at multiple parameters. A reviewing case examples based on actual patients evalu-
change in R5 by 30% to 35% has been found to reflect a ated in a pediatric pulmonary clinic. The first case is that
positive response to bronchodilators.14,42 Komarow et al17 of a 6-year-old girl who presented with a chronic cough
reported that resistance at 10 Hz (R10) and AX had the of several years. She had normal spirometry (FEV1,
best profiles based on the receiver operating characteris- 114%; FEF25%-75%, 79%) without significant change to
tic for detecting a significant bronchodilator response. bronchodilators. IOS in this patient showed normal
A 28.6% change in R10 and a 229.1% change in AX R5 and R20 but elevated AX (26.97 cm H2O/L) and
were reported as the optimal cutoff points. depressed X5 (23.7597 cm H2O/L/s, 130% of normal).
She also demonstrated a positive response to broncho-
IOS has also been used in bronchoprovocation testing.
dilators, with a 244.5% change in AX and a 239%
A typical response will show an increase in R5, R20, and
change in X5 (Fig 2). The patient was, therefore, started
Fres with a decrease in X5.43 Bailly et al43 reported that
on inhaled corticosteroids to control her symptoms, and
X5 was the only parameter sensitive enough to detect
she demonstrated good clinical improvement.
bronchial hyperreactivity and that a 20% decline in
FEV1 correlated with a 50% decrease in X5. Other Another patient seen in the same clinic was a 9-year-old
studies have reported similar findings,44,45 whereas boy with a history of corrected double aortic arch,
Vink et al46 also demonstrated a correlation between residual tracheomalacia, and suspected persistent asthma.
decreased FEV1 and increased R5 and R10. When used He had persistently abnormal spirometry (baseline
with IOS, lower doses of bronchoprovocative agents are FEV1, approximately 60%, FEF25%-75%, approximately
required to induce measurable and significant broncho- 40%), with flow-volume loops consistent with intratho-
constriction.47,48 Indeed, Schulze et al49 showed signifi- racic obstruction. These persistent abnormalities made
cant increases in resistance well before a response was objective assessment of his underlying, coexistent
seen in FEV1 at lower doses of methacholine, suggesting asthma difficult. Thus, the patient underwent IOS,
that oscillation techniques are more sensitive than which showed normal values (R5, 113%; R20, 78%),
spirometry. except for a mildly decreased X5 (23.25 cm H2O/L/s,
137% of normal), without significant response to bron-
One area of difficulty in the management of pediatric chodilators in any parameter (Fig 3). As a result, the
asthma is the prediction of loss of disease control.50 patient was able to be weaned successfully from high-
Some pediatric patients may have difficulty verbalizing dose combined inhaled corticosteroids and long-acting
respiratory symptoms, whereas others may have diffi- b-agonists.
culty perceiving a change in their respiratory status.51
Objective parameters to predict loss of asthma control, Limitations of IOS
including traditional spirometry and exhaled nitric Although IOS has many useful clinical applications, the
oxide levels, do not appear to accurately reflect a decline procedure has some limitations. First, the procedure is
in asthma control.52-54 In a recent study, Shi et al50 dem- effort-independent compared with spirometry, but
onstrated that children with controlled asthma who patients still need to be cooperative to generate valid
have increased peripheral airway IOS indexes are at risk results. Second, spirometry is currently more widely
for losing asthma control, which suggests that moni- adopted and better studied15,35,36; therefore, interpreta-
toring small airway function by IOS can be useful in tion of its results often are more straightforward to the
identifying patients who are at risk for losing asthma practitioner. Research remains ongoing about the
precise meaning, interpretation, and clinical application tion on restrictive states,9 although more research into
of IOS parameters, especially in less common disease this area is needed.
states such as childhood interstitial lung disease or in
settings such as the ICU where the forced oscillation Coding and Billing Considerations
technique may have applications for sedated patients15 For US practitioners, IOS can be billed using Current
or those receiving ventilation.56 Furthermore, the ATS Procedural Terminology code 94728. At present, the
noted that reference values for IOS are primarily available Centers for Medicare & Medicaid Services assigns 0.26
for non-Hispanic white children,36 although data from physician work relative value units for interpretation of
other populations are becoming available.7,57-60 As dis- IOS. If the physician is only doing the interpretation and
cussed, IOS is well suited for conditions involving airway does not own the equipment, a -26 modifier is used. When
obstruction, but it may not provide definitive informa- performed in a nonfacility, the global reimbursement
Figure 3 – Impulse oscillometry results in a 9-y-old boy with asthma and persistent abnormal spirometry who had vascular ring repair during infancy.
See Figure 1 and 2 legends for expansion of abbreviations.
journal.publications.chestnet.org 845
is 1.35 relative value units, including both the tech- 10. Smith HJ, Reinhold P, Goldman MD. Forced Oscillation Technique
and Impulse Oscillometry. Lung Function Testing: European
nical component and the physician interpretation. In Respiratory Society Monograph. Sheffield, England: European
general, a -25 modifier should be appended to the Respiratory Society; 2005:72-105.
evaluation and management code when performed on 11. Finucane KE, Dawson SV, Phelan PD, Mead J. Resistance of intra-
thoracic airways of healthy subjects during periodic flow. J Appl
the same day of service. It should also be noted that Physiol. 1975;38(3):517-530.
most payers consider IOS to be for patients who are 12. Lándsér FJ, Nagles J, Demedts M, Billiet L, van de Woestijne KP.
A new method to determine frequency characteristics of the respi-
unable to perform spirometry, although there are clinical ratory system. J Appl Physiol. 1976;41(1):101-106.
situations as discussed herein where the two tests may 13. Shi Y, Aledia AS, Tatavoosian AV, Vijayalakshmi S, Galant SP,
be complementary. For this reason, IOS is not generally George SC. Relating small airways to asthma control by using
impulse oscillometry in children. J Allergy Clin Immunol.
billable on the same day as spirometry or other pulmo- 2012;129(3):671-678.
nary function tests. 14. Marotta A, Klinnert MD, Price MR, Larsen GL, Liu AH. Impulse
oscillometry provides an effective measure of lung dysfunction
Conclusions in 4-year-old children at risk for persistent asthma. J Allergy Clin
Immunol. 2003;112(2):317-322.
IOS is a useful tool in the diagnosis and evaluation of 15. Beydon N, Davis SD, Lombardi E, et al; American Thoracic Society/
pediatric and adult patients with asthma and obstructive European Respiratory Society Working Group on Infant and
Young Children Pulmonary Function Testing. An official American
lung diseases. IOS can be performed easily in children Thoracic Society/European Respiratory Society statement: pulmo-
aged , 5 years, making it useful in children unable to nary function testing in preschool children. Am J Respir Crit Care
Med. 2007;175(12):1304-1345.
perform traditional spirometry. IOS may be more sensi- 16. Desager KN, Cauberghs M, Naudts J, van de Woestijne KP.
tive than spirometry at identifying pathology in the Influence of upper airway shunt on total respiratory impedance in
infants. J Appl Physiol (1985). 1999;87(3):902-909.
peripheral airways and may have better predictive value
17. Komarow HD, Skinner J, Young M, et al. A study of the use of
than spirometry in identifying patients with potential impulse oscillometry in the evaluation of children with asthma:
loss of asthma control. IOS allows bronchoprovocation analysis of lung parameters, order effect, and utility compared with
spirometry. Pediatr Pulmonol. 2012;47(1):18-26.
testing at lower doses of methacholine. Research is 18. Takeda T, Oga T, Niimi A, et al. Relationship between small airway
ongoing regarding the utility of IOS in other pulmonary function and health status, dyspnea and disease control in asthma.
Respiration. 2010;80(2):120-126.
conditions.
19. Nève V, Edmé JL, Devos P, et al. Spirometry in 3-5-year-old chil-
dren with asthma. Pediatr Pulmonol. 2006;41(8):735-743.
Acknowledgments 20. Scichilone N, Contoli M, Paleari D, et al. Assessing and accessing
Financial/nonfinancial disclosures: The authors have reported to the small airways; implications for asthma management. Pulm
CHEST that no potential conflicts of interest exist with any companies/ Pharmacol Ther. 2013;26(2):172-179.
organizations whose products or services may be discussed in this 21. Oppenheimer BW, Goldring RM, Herberg ME, et al. Distal airway
article. function in symptomatic subjects with normal spirometry following
World Trade Center dust exposure. Chest. 2007;132(4):1275-1282.
22. Pisi R, Tzani P, Aiello M, et al. Small airway dysfunction by
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