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Impulse Oscillometry (IOS)

Impulse Oscillometry

Impulse Oscillometry

Impulse Oscillometry

Impulse Oscillometry

Impulse Oscillometry

IOSbasic9e1.pmd
02 - 2006 Smith

Hans-Juergen Smith
VIASYS Healthcare GmbH
Leibnizstr. 7, D-97204 Hoechberg
Germany
Phone: +49 (931) 4972 190
Fax: +49 (931) 4972 62 190
E-Mail: Hans.Smith@viasyshc.com

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Impulse Oscillometry

Impulse Oscillometry (IOS)


Page
Advantages of Impulse Oscillometry (IOS)

Impulse Oscillometry (IOS) - principle

Resistance

Capacitance

Inertance

Important parameters

Typical examples

Normal lung function

10

Proximal obstruction (central)

11

Distal obstruction (peripheral)

12

Pulmonary restriction

13

Extra thoracic airway obstruction

15

General recommendations for the measurement

15

Interpretation of

IOS examinations

16

Forced spirometry report

18

Impulse Oscillometry report

19

Oscillometry in comparison to conventional techniques

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Impulse Oscillometry
Advantages of Impulse Oscillometry (IOS)
IOS complements conventional function diagnostics (spirometry, wholebody plethysmography, occlusion, diffusion, compliance)

IOS with proven spirometry / flow/volume application


!

Determination of static ( VC, ERV, ...) and dynamic (FVC, FEV1, FEF 50, ...) flow/
volume parameters.

Features of Impulse Oscillometry


!

Determination of differentiated and specific input impedance parameters (R5, R20,


X5, Fres, Z5).

Because of the artificial test signal (impulse) almost independent of co-operation


and therefore especially suited for use in paediatrics (down to 2 years of age),
geriatrics, occupational medicine as well as additional special applications.

Assessment and differentiation of lung function in resting condition of the patient,


i.e. normal tidal breathing situation.

Sensitive determination of obstruction.

Differentiation between proximal (central airways) and distal (peripheral airways)


components of pulmonary obstruction.

Sensitive detection and differentiation of extra thoracic changes.

Safe method for differentiation between respiratory collapse and obstruction.

Airway impedance via complete VC-manoeuvre to answer further clinical questions.

Recorded parameters provide valuable information for early diagnosis of pulmonary


diseases and distribution analysis.

Automatic graphic interpretation of measurement on the basis of a lung-thorax


model for improved patient information

Breath by breath analysis for determination of differentiated flow- and volume


dependent, in- and expiratory parameters.

IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
Attributes of Impulse Oscillometry
!

Impulse test signal provides extreme broad spectrum of frequencies


(>0 Hz - 100 Hz) for improved differential diagnostics.

Quick (30 s recording time), non invasive, objective and differentiated


determination of respiratory input impedance.

High resolution with maximal 10 measurements per second.

Specific information in combination with spirometry, occlusion and diffusion but


also with whole-body plethysmography or compliance.

Low technical expenditure and no costs for disposibles.

Portable when used with a notebook computer.

IOS application window


!

For comprehensive differential diagnostics.

Differentiated and sensitive determination of bronchial hyperreactivity of both


provocation and spasmolysis independent of co-operation (also in combination with
spirometry).

Trend analysis, using the low intra individual variability of different parameters.

Limits of oscillometry
!

Detection and differentiation of restrictive diseases is possible only in higher degree


of disease.

A further differentiation between distal obstruction and distal restriction is only


possible with additional determination of VC (Spirometry) or RV (whole-body
plethysmography).

IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
Impulse Oscillometry (IOS) - principle
Principle of Impulse Oscillometry for determining respiratory input impedance Zrs.

Terminating
Resistor

Impulse-Generator
(Loudspeaker )

Y-Adapter
Pneumotachograph

Zrs
Flow Transducer

Zrs = Pg / V'g = R + jX

V'm = V'r & V'g

Pressure Transducer
Pm = Pr & Pg
A characteristic feature of Impulse Oscillometry is that pulmonary impedance is not
derived from respiratory signals but from the pressure-flow relationship of artificial
impulse-shaped test signals which are produced by an external generator. These artificial
signals are superimposed on the respiratory tidal breathing waveform of the patient in the
Y-adapter while the patient simply inhales ambient air via mouthpiece, pneumotachograph
and terminating resistance (< 0.1 kPa/l/s). The advantage of artificial test signals is the
incomparably higher frequency contents with relatively high consistency as far as
frequency range and amplitude are concerned, so that a thorough differentiation of
pulmonary function is possible.
IOSbasic9e1.pmd
02 - 2006 Smith / ios1pzpe.p65

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Impulse Oscillometry
Respiratory resistance
Resistance model - Time course of pressure P and flow V' (top) by Fast Fourier Transformation (FFT) and quotient calculation transferred to the spectral course of resistance R
and reactance X via frequency (bottom).

P, V' time trend

V' [l/s]

P [kPa]

1.2

Resistance model

0.6

0.3
0.2
0.1

35 ms
0

40

80

120

t [ms]
time domain

FFT
P / V' = R + jX
frequency domain
extrathoracic

R, X spectra

R, X
central

[kPa/l/s]

0.2

R=0,2
peripheral

0,1

X=0

Weibels trumpet
model

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02 - 2006 Smith / ios3rrfe.p65

10

20

30

40 F [Hz]

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Impulse Oscillometry
Capacitance

Derived from negative range of reactance

Capacitance model - Time course of pressure P and flow V' (top) by Fast Fourier Transformation (FFT) and quotient calculation transferred to the spectral course of resistance
R and reactance X via frequency (bottom).

P, V' time trend

P [kPa]

V' [l/s]
2

Capacitance model

0.2
0.1

-1

-0.1

40

100 ms
120 t [ms]

80

time domain

FFT
P / V' = R + jX
frequency domain

Weibels
trumpet
model

R, X spectra
R , X [kPa/l/s]

R=0

X= 1/
C

- 0,1
pulmonary

IOSbasic9e1.pmd
02 - 2006 Smith / ios4crfe.p65

( C=capacitance)

0,2

10

20

30

40 F [Hz]

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Impulse Oscillometry
Inertance

Derived from positive range of reactance

Inertance model - Time course of pressure P and flow V' (top) by Fast Fourier Tranformation (FFT) and quotient calculation transferred to the spectral course of resistance R
and reactance X via frequency (bottom).

P, V' time trend


V' [l/s]

P [kPa]

0.2

0.1

-1

-0.1

Inertance model

80 ms
0

40

80

120

t [ms]
time domain

FFT
P / V' = R + jX
frequency domain
extrathoracic

R, X spectra

R, X
central

[kPa/l/s]

0.2

( I=inertance)

I
X=

0,1

R=0

Weibels trumpet
model
IOSbasic9e1.pmd
02 - 2006 Smith / ios5irfe.p65

10

20

30

40 F [Hz]

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Impulse Oscillometry
Important parameters
Impedance

Z = R + jX

Impedance describes a complex (mathematical sense) airway resistance which includes two
components, the real resistance R and the imaginary reactance X.

Resistance R (Energy Consumption)


R at 5 Hz: R5 Total respiratory resistance
R at 20 Hz: R20 Proximal respiratory resistance
Resistance consumes ventilatory energy and converts it
into heat.

predicted

Reactance X (Capacitive-inertial storage of energy)


Reactance consists of two components. The positive
inertial portion increases with frequency and the negative
capacitive portion decreases frequency-inversely.

X=

1
C

I
C
I

X at 5 Hz:
f at X=0:

=2f

predicted

Capacitance (Elasticity)
Inertance (Inertia)

X5 Distal capacitive reactance


Fres Resonant frequency

The ability to store energy in the capacitance


(elastic recoil) is prerequisite for passive expiration.
Inertance has minor clinical relevance!

Impedance Z
Respiratory impedance, i. e. the interaction between
resistive and reactive properties of the respiratory
system, is primarily measured by the oscillometric
method.
Z at 5 Hz:

Z5 Amplitude of respiratory
impedance at 5 Hz

IOSbasic9e1.pmd
02 - 2006 Smith / ios2rxze.p65

Z5= R52

X5

predicted

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Impulse Oscillometry
Typical example
Normal lung function

Resistance spectrum R(f)

Reactance spectrum X(f)


normal

abnormal

predicted

predicted

abnormal

normal

Total respiratory resistance R5 is within the predicted normal range, below the red hatched
abnormal level. The resistance spectrum R(f) is independent of frequency. Distal capacitive
reactance X5 is within the normal range (higher than the blue coloured area). Resonant
frequency Fres is normal.

Interpretation graph
Structural parameters of the Mead
model

Rc

Flow/volume

Ers
Normal lung function. The flow and
volume are within the predicted
normal range.

Rp
volume
Model interpretation not applicable for
children below 7 years!
Note, not the absolute values of Rc and Rp
have clinical relevance but their
relationship.
In case of normal lung function Rc is equal
in shape compared to Rp.
Ers has no clinical relevance.

IOSbasic9e1.pmd
02 - 2006 Smith

Degree of airway obstruction according to


R5 and X5.
Page 10

Impulse Oscillometry
Typical example
Proximal obstruction (central)

Resistance spectrum R(f)


abnormal

normal

Reactance spectrum X(f)


normal
predicted

predicted

abnormal

The Total respiratory resistance R5 is high and within the abnormal range. The resistance
spectrum R(f) is independent of frequency. I.e. Proximal respiratory resistance R20 is
similar to Total respiratory resistance R5. Distal capacitive reactance X5 is completely
within the normal range, as is Resonant frequency Fres.

Interpretation graph
Structural parameters of the Mead model

Rc

or

Ers

Flow/volume
The expiratory portion of the curve
is clearly concave.

Rp
volume
Model interpretation not applicable for
children below 7 years!
Note, not the absolute values of Rc and Rp
have clinical relevance but their
relationship.
In case of proximal obstruction Rc is larger
or equal in shape compared to Rp. Ers has
no clinical relevance.

IOSbasic9e1.pmd
02 - 2006 Smith

Degree of obstruction according to R5 and


X5.
Page 11

Impulse Oscillometry
Typical example
Distal obstruction (peripheral)

Resistance spectrum R(f)

abnormal

Reactance spectrum X(f)

normal
predicted

normal

predicted

abnormal

Total respiratory resistance R5 is within the red coloured abnormal range. The resistance
spectrum R(f) is frequency dependent, becoming less at higher frequencies. Proximal
respiratory resistance R20 is considerably lower than R5. Distal capacitive reactance X5 is
reduced into the abnormal range and Resonant frequency Fres is shifted to the right, i.e.
towards higher frequencies.

Interpretation graph
Structural parameters of the Mead model

Rc

Flow/volume

Ers
The shape of the curve is similar to
that of proximal obstruction, but is
normally more exaggerated. When
airway collapse is a feature, the
expiratory portion of the curve shows
a very pronounced appearance.

Rp
volume
Model interpretation not applicable for
children below 7 years!
Note, not the absolute values of Rc and Rp
have clinical relevance but their
relationship.
In case of distal obstruction Rp is larger in
shape compared to Rc.
Ers has no clinical relevance.

IOSbasic9e1.pmd
02 - 2006 Smith

Degree of obstruction according to R5 and


X5.
Page 12

Impulse Oscillometry
Typical example
Pulmonary restriction

Resistance spectrum R(f)

abnormal

Reactance spectrum X(f)


normal
predicted

normal

predicted

abnormal

Total respiratory resistance R5 is within the normal range. The resistance spectrum R(f) is
independent of frequency. Only in severe impairments, Distal capacitive reactance X5 is
reduced and within the abnormal range and Resonant frequency Fres is shifted to the right
to a higher value. The reduced Vital capacity VC in the Z5 impedance graph may be better
suited to indicate the presence of pulmonary restriction.

Interpretation graph
Structural parameters of the Mead model

Rc
Ers

Flow/volume
The curve is of normal shape,
however Vital Capacity VC is
considerably reduced.

Rp
volume
Model interpretation not applicable for
children below 7 years!
In case of pulmonary restriction the green
Ers bar (lung and thorax) should be
increased, however this is in less than 50%
of all clinical examinations the case. Ers
can't be used to derive clinical decisions.
Degree of obstruction according to R5 and
X5.

IOSbasic9e1.pmd
02 - 2006 Smith

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13

Impulse Oscillometry
Typical example
Extra thoracic airway obstruction

Resistance spectrum R(f)


peak

Reactance spectrum X(f)


normal

abnormal

predicted
plateau

normal

predicted

abnormal

Total respiratory resistance R5 and the Proximal respiratory resistance R20 are both high
and within the abnormal range. The resistance spectrum R(f) is independent of frequency,
rarely a peak can be observed on the resistance spectrum. The reactance spectrum X(f)
may be within the normal or the abnormal range, however, Extra thoracic airway
obstruction produces a typical plateau in the normally continuous reactance curve.
The plateau is normal for children below 4 years of age.

Interpretation graph
Flow/volume

Structural Parameters of the Mead Model

Rc

The curve shows a typical plateau in


both the inspiratory and expiratory
parts of the flow/volume-curve.

Ers
Rp
volume
Model interpretation is generally not
applicable to patients with Extra thoracic
airway obstruction.
Usually the interpretation graph presents a
peripheral obstruction which is wrong,
because the model interprets the low mouth
compliance as pulmonary compliance.

IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
General recommendations for the measurement
Instruct every patient!

Patient:

To allow reproducible and reliable measurements:


Sitting in upright position while measured
Head in neutral position or slight extension (not in rotation or flexion)
Nose clipped
Cheeks supported with hands to avoid the "upper airway shunt"

"
"
"
""

To avoid artefacts in the mouth chamber:


" Mouthpiece (plastic) tight between teeth
" Tongue beneath moutpiece
"" Lips firmly closed around mouthpiece
(even small gaps create remarkable pressure drops and therefore low or
zero resistance)
Take care on tight belts and clothes (increases peripheral resistance).

Assistant: A high reproducibility of all parameters can be achieved if the patient is


spontaneously breathing without advice on breathing frequency or deepness
of breath. Most of the important parameters base on tidal breathing recording.

Test:

1. The patient should be instructed before the measurement starts.


2. The patient has to adapt to the mouthpiece after clicks of the loudspeaker are
audible.
3. If regular spontaneous breathing is visible, the measurement can be started.
Test design for data acquisition
! Differential diagnostics:
30 s tidal breathing (min. 4 br. cycles)
! Screening:
min. 4 breathing cycles tidal breathing
! Test of hyperreactivity: min. 4 breathing cycles tidal breathing
4. Stop measurement before the patient is allowed to release the mouthpiece

Assessment of quality:
" Regularity of time trend of volume
" Z5-volume-graph regarding to artefacts
" Parameters R5 and X5 in their expected relation to predicted values
" In children (< 5 years) time trend of Z5

IOSbasic9e1.pmd
02 - 2006 Smith

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15

Impulse Oscillometry
Interpretation of IOS examinations
1. Standard interpretation
R5
X5

Total respiratory resistance


Distal capacitive reactance
in cmH2O

(normal, if lower than 150 % of R5pred)


(normal, if higher than X5pred-0.15 kPa/(L/s))
(normal, if higher than X5pred-1.5 cmH2O/(L/s))

Lung function is abnormal if either R5 or X5 or both parameters are in the


abnormal range!
R (f)
X (f)

Resistance spectrum
Reactance spectrum

(5 Hz - 35 Hz)
(5 Hz - 35 Hz)

The frequency response of related resistance and reactance spectra allows a further
qualification in proximal, distal or extra thoracic obstruction and restriction.
Z5-volume-xy-graph

Impedance-volume-graph

Clear distinction between airway collapse and obstruction. Further differentiation


between normal, obstructive, emphysematic and restrictive lung function impairments.

2. Extended interpretation
R20

Proximal respiratory resistance

Z5-trend report

(normal, if lower than 150 % of R20pred)

Amplitude of respiratory impedance at 5 Hz

The Amplitude of respiratory impedance is very well suited for trend reports and
volume related xy-graphs because of its low variability.

3. Assessment of bronchial hyperreactivity (Challenge)


R5
Fres

Total respiratory resistance


Resonant frequency

(50 % increase = 20 % decrease of FEV1)


(40 % increase = 20 % decrease of FEV1)

As soon as one of these two parameters passes the threshold, the challenge has to be
terminated.
IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
4. Assessment of bronchial hyperreactivity (Dilatation)
R5
Fres

Total respiratory resistance


Resonant frequency

(20-25% decrease = 15% increase of FEV1)


(20 % decrease= 15% increase of FEV1)

As soon as one of these two parameters passes the threshold, the patient is
hyperreactive

5. Breath by breath analysis


Static resistance/reactance
Dynamic resistance/reactance

Volume dependence of respiratory tract


Flow dependence of airways

For early diagnostics of pulmonary diseases.

6. Automatic model interpretation - structural data


Applicable in patients from 7 years of age and without extra thoracic stenosis !
Structural parameters are calculated out of spectral data with help of a 7-element-model
which was suggested by Mead. The relation between Rc and Rp, not there absolute
values, locate the obstruction in a functional way. Approximately 80% of all
interpretations are correct.
The elasticity of lung and thorax Ers in contrary is inaccurately determined and does not
allow any clinical derivation.
Lung model suggested by Mead contains
7 elements (structural parameters) which
are named Rc, Rp, Lc, Cl, Cb, Cw
and Cm.
Clinical relevant structural parameters
and their reliability:
Rc Central resistance
> 80%
Rp Peripheral resistance
> 80%
(Ers Elastance of lung & thorax < 50%
Ers = Cl parallel to Cw)
Note, relationship between Rc and Rp is relevant, not their absolute values!
Graphical report can be used for patient information.
Do not derive clinical decisions from model interpretation!
IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
Interpretation of forced spirometry report
Female patient with COPD
Last Name:
Identification:
Physician:
Age:
Weight:
Sex:
Pred. Module:

First Name:

Peripheral
002960018
K...
42 Years
153 lbs / 70 kg
female
IOS-Standard

Ward:
Height:
Race:
BSA:
Operator:

Obstruction

65 inch /165 cm
1.7 m2
Smith

Pred
Act
%(A1/P)
--------------------------------------------------Date
050796
Time
04:16PM
VC IN...............
FVC.................
FEV 1...............
FEV 1 % VC MAX......
PEF.................

[L]
[L]
[L]
[%]
[L/s]

3.05
2.99
2.57
81.1
6.29

2.69
2.56
1.27
47.4
2.47

88.0
85.3
49.5
58.4
39.3

FEF 25.............. [L/s]


5.62
1.26
22.5
FEF 50.............. [L/s]
3.97
.684
17.2
FEF 75.............. [L/s]
1.71
.234
13.7
FIV 1............... [L]
2.67
PIF................. [L]
3.39
---------------------------------------------------

10

No Restriction

Proximal obstruction ?

Distal obstruction ?

Flow Ex [L/s]

Flow limitation of higher degree


and normal Vital capacity

Vol [L]
0
2

-5

Flow In [L/s]

Report of the forced flow/volume-measurement of a patient with COPD. The parameters


FEV1, PEF and FEF xx indicate a higher degree of flow limitation, probably caused by a
severe obstruction. As the outcome of the test is non-specific, a definite differentiation
between proximal and distal airways is not possible!
The Forced vital capacity FVC in the normal range excludes a restrictive disease.

Spirometric parameters are non-specific


IOSbasic9e1.pmd
02 - 2006 Smith

!
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18

Impulse Oscillometry
Interpretation of Impulse Oscillometry report
Female patient with COPD
Last Name:
Identification:
Physician:
Age:
Weight:
Sex:
Pred. Module:

First Name:

Peripheral
002960018
K...
42 Years
153 lbs / 70 kg
female
IOS-Standard

Obstruction

Ward:
Height:
Race:
BSA:
Operator:

65 inch /165 cm
1.7 m2
Smith

Pred
Act
%(A1/P)
--------------------------------------------------Date
050796
Time
04:05PM
--------------------------------------------------VT.................. [L]
0.67
Zrespir........ [kPa/L/s]
1.34
Resonant Frequency. [1/s]
31.1
R at 5 Hz...... [kPa/L/s]
R at 20 Hz..... [kPa/L/s]

0.37
0.31

1.01
0.65

X at 5 Hz...... [kPa/L/s]

-0.04

-0.61

1. Total respiratory
resistance (R5)
in abnormal range
(>150%)
Also Proximal respiratory
resistance (R20) abnormal

271
211

Z5
Rcentral....... [kPa/L/s]
0.13
6
Rperipheral.... [kPa/L/s]
1.99
------------------------------------------------------

2.

Extreme decrease of Distal capacitive

6. Rc < Rp

reactance (X5) lower than border value at


-0.24 kPa/l/s
(X5pred - 0.2 kPa/L/s)

indicates
a distal obstruction

R[kPa/l/s]

X[kPa/l/s]

4. Re4

markable
loops
indicate airway collapse

3. Distal obstruction because of frequency


dependence of R(f) and decrease of X5

X(f)

R(f)
5

3
1

5. Plateau in reactance course specifies proximal

6. Model interpreation of a distal

obstruction as extra thoracic stenosis

obstruction

Impedance parameters are objective, differentiated and specific


IOSbasic9e1.pmd
02 - 2006 Smith

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Impulse Oscillometry
Oscillometry in comparison to conventional techniques

Rpul
CL

Rocc

sR
R
ITGV

R5
X5

FEV1
FEF 75

Comparison of IOS (R5, X5) with resistance- and volume-equivalents acquired by


spirometry (FEV1, FEF 75) whole-body plethysmography (sR, R, ITGV), occlusion (Rocc)
and compliance measurements (Rpul, CL ).

extra
thoracic
central

peripheral

pulmonary
chest wall

The various methods of lung function testing also assess different parts of the pulmonary
system related to the particular pressure registration.
Depending on the disease, the reported parameters can have the same values but they can
also differ considerably from each other.
The knowledge of the range of acquisition and the specificity of any parameter of the
individual method can be helpful for further differentiation of the respiratory tract.

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