Iranian Society of Pulmonology

Pulmonary Function Tests

Impulse oscillometry (IOS)

- simplified -

Hans-Juergen Smith, Germany

Sr. Product Manager Pneumonology
Ahvaz – Iran
17th February
Oscillometric lung function testing
Features of the method

Evaluation of
15 – 30 seconds of normal breathing

 Effortless examination
 No breathing manoeuvres

 No shutter or valves
 No box
 No foreign- or calibration gases
IOS …why?
Advantages
Patient
 Spontaneous resting breathing
 “Passive” co-operation
 Minimal impact on test results

Operator
 Easy to instruct
 Automated quality control

Pneumonologist
 Nearly all patients can be examined,
independent on age or disease or stage of disease
(children, adults, elderly, severe diseased)
 Integrated classification and interpretation
 Differentiated and complementary information
 Can be used when spirometry is not possible

IOS simplifies examination for all involved persons.

Limits of spirometry
Determination of flow limitation

 Forced/maximal breathing is UNEQUAL to tidal breathing

 Early diagnosis of pulmonary diseases NOT possible
 Flow limitation is UNEQUAL to obstruction
 Small airways are not safely differentiated
 Superimposing effects, dominance of central airways

Non-specific character of spirometry!

- Expertise of physician required! -

Further more
 Influence of the test itself (Deep inhalation)
 Functional and/or fixed conditions of the upper
airways
 Pain, instruction cooperation is incorporated in
test result!
Basic functionality
SentrySuite integration

Limits of spirometry can be compensated by utilizing IOS.

Measurement applications
 Impulse Oscillometry (IOS)
 Spirometry, flow-volume, MVV

Options
 Pre-post reversibility testing
 Bronchial challenge (APS)
 Anterior rhinomanometry
 Bedside
IOS measuring head
Methodological details
Respiratory Impedance
( )
= = +
( )

2 INDEPENDENT measurement
categories

Airways resistance Rrs

Lung reactance Xrs

Forced spirometry
=
V’ Pm
Flow-volume-parameters
Impulse signals FEV1, FVC, MFEFxx,…
Respiratory signals
Indications for IOS testing
Identical to spirometry

Relevant clinical question are answered based on

spontaneous resting breathing.

Assessment of resting conditions

 Only passive co-operation (pediatrics, geriatrics, occupational
medicine, severe diseased…)
Trend reports
 Excellent intra-individual reproducibility CV% < 10%!
Determination of abnormal Lung function
 Measurement of airways resistance
 Independent determination of peripheral airways
 Classification of abnormality
Bronchial hyperresponsiveness
 Degree of reversibility
 Non-specific and specific challenge testing
Clinical relevance of oscillometry
Detection of pulmonary obstruction

 Sensitive and differentiated determination of

proximal and distal pulmonary obstruction
 Intra breath analysis for phenotyping of obstruction
 Equivalents of lung elasticity and lung volume
 Evidence of bronchial instabilities (collapse)
 Functional characteristic of extra thoracic airways

Differential diagnostics oriented on disease

 Asthma - Central and distal airways diagnostics
- Reversibility, hyperresponsiveness
 COPD - Small and distal airways diagnostics
- Intra breath analysis
- Detection of expiratory flow limitation (EFL)
Methodological details of IOS

FOT (IOS) determines breathing mechanics by

superimposing small external pressure signals on the
spontaneous breathing of the subject.

Smith HJ. et al. Forced oscillation technique and impulse

oscillometry. European Respiratory Monograph 31, 2005; 10: 72-105
 External test frequency generation
Physiological response on external signals

Impulse spectrum
… 5 – 20 … Hz

Extra
thoracic

airways airways
Peripheral Large
! 5 & 20 Hz
Central
Small
Impulse spectrum 5 Hz Pulmonary
differentiates Chamber
respiratory tract. Chest wall

Breathing frequency: 0.25 to 0.35 Hz

Lung: Morphology of a trumpet
According to Weibel
Cross-
Genera- sectional Resistance
tion area [cm²] [kPa/(L/s)]

0.06
Larynx
Large
2.5
Trachea airways
0.10
Bronchi (Rrs > 80%
contribution)
2.0
Rrs
8-10

5.0
Bronchioles 17 0.04
1.8 x 10²
Peripheral
airways
9.4 x 10²
(Xrs > 80%
Alveolar Ducts 5.8 x 10³ Xrs contribution)
Alveoli 24 5.6 x 107

Weibel, Morphometry of the Human Lung, Springer 1963

Data acquisition
Key message
Impulse oscillometry provides a means of evaluating within-
breath behavior of oscillatory mechanics at high temporal
resolution.

Ohishi J. et al. Application of impulse oscillometry for within-breath

analysis in patients with chronic obstructive pulmonary disease: pilot
study. BMJ Open 2011; 2: 1-8
 Calibration of the IOS head
Reference impedance for complete check

Flow-volume-calibration Reference impedance Screen

flap
Daily, before first measurement
- With filter and opened screen flap -

Measurement of reference impedance (R5Hz=0.2 kPa/(L/s),

X5Hz=0 kPa/(L/s) allows complete check of IOS measuring head.

System check with reference impedance (as needed)

 Assemble reference impedance after flow-volume-calibration
 Select “SeS QM validation” patient
 Perform IOS measurement with closed screen flap
 If 0.18 < R5Hz < 0.22 AND X5Hz = 0 system is ok, otherwise
service is required
 Appropriate patient instructions
Notes for reliable measurement results

Patient should be examined well balanced

and free of stress (10-15 min rest before)

 Patient should sit in upright position

 Head straight or in slight extension
 Nose clipped

Cheeks supported with palms of hands (to

ovoid upper airways shunt).

Lips firmly closed around mouthpiece.

- No leakage! – Visual inspection!

 Patient should breath spontaneously

 Best repeatability at his/her point
of lowest work of breathing (WOB), i.e.
regular VT and BF
One button control for operator
Data recording and quality check

Automated data recording launched with “Start” (F1)

 Detection and monitoring of tidal breathing
 20 s data acquisition (default)
 Presentation of FRC stability track
 Automated stop and data storage

Automated quality assessment (quality bar becomes green)

 Minimal 3 reproducible trials should be recorded
 In non-cooperative patients number of trials can be increased up to 10
 Improvement of test results
 Stabilization of final outcome

Failure recognition by multi-trial architecture

 Detection of pulmonary artifacts
 Detection of adaptation problems
Quality improvement!
Mean versus median calculation

Quality of final test result (best) is higher than quality of single

measurement (trial)! - Mean calculation after artifact rejection.

Automated artifact rejection by

1. Z5Hz – CV% > 15% (default)
2. Significant statistical difference from mean
3. Median determination (like all other methods)

! Artifact rejection and mean calculation is a new and

outstanding feature of IOS!

! Possible improvement of test results in non-

cooperative patients or young children.
Report screen
Record trials (Start/F1) until quality bar is green

rejected

accepted

Rrs spectra
rejected
Xrs spectra
rejected

Quality control Quality bar

Within trial quality assessment
Time trend of result parameters

Regularity of spirogram
 VT and BF unrestricted and regular
providing stable FRC and lowest WOB > best repeatability!

Regularity of Z5Hz-variation
 Independent on the amplitude/degree of variation!
 No visible artifacts
Swallowing
Leakages Volume

Z5Hz

!
Coherence (Co5Hz) is not a measure of quality but a measure
of inhomogeneity of the lung, e.g. clinical information!
Any questions so far?
7 (2 most) important clinical
parameters
The key concept of the forced oscillatory respiratory
mechanics is the “impedance” (Z), the spectral (frequency
domain) relationship between pressure (P) and airflow (V’).

Oostveen E. et al. The forced oscillation technique in clinical

practice: methodology, recommendations and further developments.
ERS Task Force. Eur Respir J 2003; 22: 1026-1041
 Total airways resistance R5Hz (1)
Resistance at 5 Hz

Resistance of the tracheo-bronchial tree against impulse pressure.

Rrs [kPa/(L/s)] Resistance spectrum
0,6

0,5
Extra thoracic Abnormal range
0,4

Central 0,3 R5Hz R20Hz

R20Hz
R5Hz 0,2 Predicted line
0,1
Small 0
airways DR5-R20%
0 5 10 20 30 40 f [Hz]

Additional resistance parameters

Chest wall  Proximal resistance (3) R20Hz
 Frequency dependence (4) DR5-R20%
 Lung reactance X5Hz (2)
Low frequent reactance at 5 Hz

Degree of peripheral obstruction, i.e. volume of accessible airways.

Elasticity of peripheral lung and thorax.

Xrs [kPa/(L/s)] Reactance spectrum

0,3

0,2

0,1
Fres
0
AX

-0,1 X5Hz
Peripheral -0,2 Abnormal range
lung -0,3
X5
0 5 10 20 30 40 f [Hz]

Additional parameters of lung periphery

 Resonant frequency (5) Fres – zero crossing of reactance spectrum
 Area index (6) AX - area from X5 to Fres up to zero-line
 Impedance Z5Hz
Primary information

Determined from the ratio of Fourier transformed (F) impulse

pressure and impulse flow.

5
(7) 5 = = 5 + 5
5

 Link between primary signals (iP, iV’) and oscillometry

parameters (R5Hz and X5Hz)
 Not differentiated – global information
 Low variability
Ideally suited for time trend, V- and V’-dependencies

* Fast Fourier transform (FFT)

Summary of important parameters
Usually employed in clinical interpretation

Already R5Hz & X5Hz allow comprehensive clinical interpretation

Main (basic) parameters

 (1) R5Hz (Total) airways resistance
 (2) X5Hz Lung reactance
Differentiated interpretation
Proximal (central) lung
 (3) R20Hz Central resistance
Distal (peripheral) lung
 (4) Diff R5-R20 Frequency dependence of Rrs-spectrum
 (5) Fres Resonant frequency
 (6) AX Reactance area
Respiratory Impedance
 (7) Z5Hz Impedance 5 = 5 + 5
Simple clinical interpretation
The major thrust for clinical application of FOT
(oscillometry) derives from a number of European clinical
research centers.

Goldman MD. Review: Clinical Application of Forced Oscillation.

Pulmonary Pharmacology & Therapeutics (2001) 14, 341–350
Reference values
From 2 years to infinite

 2 to 12 Dencker/Malmberg
 13 to 17 Berdel/Lechtenboerger
 18 to 60 Vogel/Smidt; extrapolation > 100
 45 to 91 Schulz
M. Dencker M, Malmberg LP. Et al. Reference values for respiratory system impedance by
using impulse oscillometry in children aged 2–11 years. Clin Physiol Funct Imaging 2006;
26: 247–250

Lechtenboerger P. et al. Resistance and Reactance Measured by Impulse Oscillometry:

Paediatric Reference Values in 614 Healthy Children and Adolescents Aged 5 to 17 Years.
Private communication.

Vogel J, Smidt U. Impulse Oscillometry – Analysis of lung mechanics in general practice and
the clinic, epidemiology and experimental research. Pmi Verlagsgruppe GmbH 1994; ISBN 3-
89119-316-5

Schulz H. et al. Reference Values of Impulse Oscillometrc Lung Function Indices in Adults of
Advanced age. Plos One 2013; 8;: 63366
 Reference values for IOS
In comparison to spirometry

IOS reference values are mostly height dependent.

In adults relatively independent on age – extrapolation possible.

FEV1 [L] R5Hz [kPa/(L/s)]

 2 to 12 years 6 0.6

Dencker/Malmberg
 13 to 17 years 4 0.4

Berdel/Lechtenboerger
 18 to 60 years 2 0.2
Vogel/Smidt
Extrapolation > 100 0 0
 45 to 91 years 5 15 25 35 45 55 65 75 85 years
Schulz Spirometry is age and height dependent!

A. Paes Cardoso, R. Ferreira, Portugal 1997

2
7
 Determination of abnormality
Automated classification

Definition of abnormality:
R5Hz Resistance - if > 140 % of predicted
X5Hz Lung reactance - difference to predicted > 0.15 kPa/(L/s)

Automated classification
Detection of flow limitation in resting breathing – DX5

Classification based on R5Hz and X5Hz and their predicted in 5 levels

Area index according to Goldman
US Goldman chart (USG chart)

Combination of relevant parameters in one area with AX

Fres
R20Hz

AX
X5Hz R5Hz Comparable to
Weibel model
 Pre-post assessment
Application of US Goldman chart

Dilatation R5Hz -20% to -25% | Fres -20%

Provocation R5Hz +40% | Fres +35%

Pre Dilatation Post

Fres

Fres

AX AX
R5Hz R5Hz

Post Provocation Pre

A. Marotta et al. “Impulse oscillometry provides an effective measure of lung dysfunction in 4-year-
old children at risk for persistent asthma” J ALLERGY CLIN IMMUNOL, August 2003, 317-322
Differentiated diagnostics
IOS is employed by health care professionals to help
diagnose pediatric pulmonary diseases such asthma and
cystic fibrosis; assess therapeutic responses; and measure
airway resistance during provocation testing.

Komarow HD. et al. Review: Impulse oscillometry in the evaluation

of diseases of the airways in children. Ann Allergy Asthma Immunol.
2011;106:191–199.
Survey of specific resistance spectra
3 characteristic spectra

Abnormal range

a) Normal lung function

b) Central obstruction
c) Peripheral obstruction (Small airways)
d) Restriction
e) Extra thoracic stenosis
Survey of specific reactance spectra
3 characteristic spectra to differentiate

Abnormal area

a) Normal lung function

b) Extra thoracic obstruction
c) Peripheral obstruction
d) Restriction
e) Extra thoracic stenosis
Evaluation of challenge testing
Differentiated tidal breathing analysis

Provocation dose PD; provocation concentration PC

PD/PC +40 R5Hz PD/PC +35 Fres

Resistance Fres
6
R5Hz 7 1 6

1
7

Reactance

1 Baseline
6 Maximal constriction ! Peripheral obstruction
7 Dilatation step
Restrictions not safely detected
Limited sensitivity of oscillometric method

 Detection of restriction by decrease of lung reactance X5Hz only in

higher degrees of disease
 VC-manoeuvre in oscillometry or in spirometry to proof restriction

Xrs [kPa/(L/s)]
Restriction
0,3 Decrease of VC
0,2 Reactance spectrum
0,1
 VC
0
Fres
-0,1 VC
-0,2 X5Hz
-0,3
0 5 10 20 30 40 f [Hz]

! TLC measurement (body, diffusion) recommended!

 Conclusion
Impulse oscillometry IOS

 Quite breathing manoeuvres are more

suitable for larger patient population
 Results are more sensitive to treatment
than spirometry – early diagnosis
 Small airways diagnostics possible

IOS is simple
 Patient is only passively cooperating
 Operator is supported in quality issues
 Physician is supported by various
classification & interpretation strategies

Introduction of a more differentiated IOS analysis and the

examination of VC-manoeuvres in a next advanced webinar.
Thanks for your attention!
Any questions?

Measurement of pre-school