The Forced Oscillation Technique

The Future of Pulmonary Function Testing?

Alexander S. Niven, MD
Clinical Assistant Professor, University of Washington
Director, Respiratory Care Services
Madigan Army Medical Center
Conflict of Interest Disclosure

Equipment loan from Viasys Inc.

 Why Look for New Techniques?

72 yo with bronchiectasis, MAC 21 yo with VCD, possible asthma

 Disadvantages of Spirometry

• Requires maximal,
reproducible efforts
• Flow limiting segment (FLS)
– Central to peripheral airways
• Maximal expiratory flow
(MEF) is dependent on
– Lung recoil pressure
– Dynamic airway resistance
– Airway properties at FLS

Pride NB. Clin Chest Med 2001; 22(4): 599-622

Evaluation of Obstructive Lung Disease

• Spirometry, bronchoprovocation testing

– Cannot reliably differentiate these patients
– Insensitive to early airway changes
Lapperre TS et al. Am J Respir Crit Care Med 2004; 170; 449-504
Fabbri LM et al. Am J Respir Crit Care Med 2003; 167: 418-424
 Forced Oscillation Technique

• Superimposed external pressure signals on

spontaneous tidal breathing
• Effort independent assessment of mechanics
– Significant pediatric literature
– Increasing interest in adult lung function testing

Dubois AB. J Appl Physiol 1956; 8: 587-94

Smith HJ. Eur Respir Mon 2005; 31: 1-34
DuBois AB, Brody AW, Lewis DH, Burgess BF. Oscillation mechanics of lungs and chest in man. J Appl Physiol 1956; 8: 587-94
 Loudspeaker

Resistor

Pneumotach

Transducer
 Methodology

• Mono or multi frequency

– 2-4 Hz to 30-35 Hz
• Continuous
– Pseudo-random noise
(PRN)
• Time discrete
– Impulse oscillation (IOS)

Modified from Smith HJ et al.

Smith HJ et al. Eur Respir Mon 2005; 31: 1-34
Impulse Oscillometry Testing

• Seated
• Head in neutral
position
• Tidal breathing
• 20 – 90 seconds
• Cheek support
when necessary
Niven A et al. Am J Respir Crit Care Med 2003; 167(7): A419
Large Airways Small Airways
 Total Respiratory Impedance (Zrs)

Small Airways Large Airways

Goldman MD. Pulm Pharmacol Ther 2001; 14(5): 341-350
 Resistance (Rrs)

Small Airways Large Airways

Rrs

Normal

Baseline

Frequency Dependence

Post
Bronchodilator COPD
 Reactance (Xrs)

Small Airways Large Airways

 Resonant Frequency (frs)

Reactance Area (AX)

Smith HJ et al. Eur Respir Mon 2005; 31: 1-34

 Normal
frs

COPD
AX

Post Bronchodilator

frs = 18 Hz

Baseline
http://sunsite.unc.edu/dave/drfun.html
 Clinical Applications

• Screening
• Upper airway obstruction
• Obstructive lung disease
– Bronchoprovocation testing
– Bronchodilator response
• Respiratory Mechanics
– Obstructive sleep apnea
 Screening
• 96 iron workers at 9/11 clean up site
• 53 noted new respiratory symptoms
– Cough, dyspnea, wheezing, sinus complaints

Smokers Nonsmokers
FVC,% pred 100 + 14 99 + 10
FEV1, % pred 97 + 15 99 + 13
FEV1/FVC 0.78 + 0.08 0.82 + 0.07
R5, cm H2O/L/s 3.9 + 0.9 3.5 + 0.8
R20, cm H2O/L/s 3.1 + 0.6 3.1 + 0.7
R5-R20, cm H2O/L/s 0.8 + 0.5* 0.5 + 0.3
AX, cm H2O/L/s 3.9 + 0.3* 1.8 + 0.1
Adapted from Skloot G. Chest 2004; 125: 1248-1255 * p < 0.01
 Large Airway Resistance
• Large particles deposit in central airways
• Increased resistance causes impulse shadow

Measurement reflects large Large Airways

airways only (increased resistance)
Central (Large Airway) Obstruction
Reactive airways at “Ground Zero”

Baseline
Pre-BD

Post Bronchodilator
Courtesy of MD Goldman
 Vocal Cord Dysfunction
• Pathologic adduction of vocal cords
– 10-15% of young dyspnea patients
• More common in females
– Perfectionism, psychiatric conditions
• Etiology may be multifactorial
– Conversion disorder
– Post-nasal drip syndrome, GERD

Morris M et al. Chest 1999; 116: 1676-1682

Newman K et al. Semin Respir Crit Care Med 1994; 15: 162-167
Christopher KL et al. N Engl J Med 1983;308:1566-1570
Vocal Cord Dysfunction

Inspiration Expiration
Inspiratory impedance “spikes” due to
variable extrathoracic obstruction from VCD

Red = Impedance (H2O/L/s)

Blue = Volume (L)
 Bronchoprovocation Testing

• Oscillometry consistently more sensitive

in the detection of small airway changes
– Greater magnitude of change
– Lower dose of challenge agent
• Histamine, methacholine
• Eucapneic voluntary hyperventilation, cold air

Hnatiuk OW et al. Chest 2000; 118(4): 198S

Evans TM et al. J Asthma 2006; 43(1): 49-55
Rundell KW et al. Can Respir J 2005; 12(5): 257-63
Evans TM et al. Chest 2005; 128(4): 2412-9
Bronchoprovocation Testing

Courtesy of MD Goldman
Bronchoprovocation Testing

Courtesy of MD Goldman
 Lung Allograft Rejection
• IOS in 22 bilateral lung allograft recipients
– 5 acute rejection, 7 bronchiolitis obliterans
– Abnormalities in R5 (9), R5-15 (10), frs (12), AX (12)

Goldman MD et al. Respir Physiol Neurobiol 2005; 148: 179-194

Ross D et al. J Heart Lung Transplant 2004; 23: S131
 Bronchodilator Response
Coefficient of Variation (%)
sGaw
Test Day
sGaw  9.3 7.8 frs
R5
frs  5.0 7.4
R5  8.4 13.5 FEV1

FEV1  3.3 3.5

IC  3.2 6.6

Gaw, frs, R5 more sensitive to airway changes but

demonstrate greater variability than FEV1
Borrill ZL et al. Br J Clin Pharmacol 2005; 59: 379-384
 CPAP Titration

Navajas D et al. Am J Respir Crit Care Med 1998; 157: 1524-1530

 Impact of Uvulopharyngoplasty

Lin CC et al. Eur Arch Otolaryngol 2006; 263: 241-7

Standardization of Spirometry

• Acceptable and reproducible data

• Reference standards
– Diverse demographics
• Interpretation strategies
• Clinical significance of measurements

Adapted from Brusasco V et al, eds. Eur Respir J 2005; 26: 319-338
 Data Collection Criteria

• Minimum data acquisition ( > 20 seconds)

• Multiple tests
• Artifacts
– Swallow, cough
– Circuit leak
– Tongue, cheeks
• Data coherence
measurements
Tongue Artifact

Goldman MD et al. Respir Physiol Neurobiol 2005; 148: 179-194

 Reference Values
Hz Male Female

Rrs n Age Rrs n Age

(cmH20/L/s) (yrs) (cmH20/L/s) (yrs)
Landser, 1982 4 - 24 2.5 (0.6) 224 26 (10)

Clement, 1983 8 - 24 ~ 2.6 442 29

Gimeno, 1992 10 2.9 (0.8) 102 50

Pasker, 1994 6 - 24 2.6 (0.6) 126 33 (12) 3.0 (0.6) 100 29 (12)

Govaerts, 1994 10 - 32 2.6 (0.7) 32 48 (15) 3.4 (0.7) 28 55 (13)

Pasker 1996 6 - 24 2.5 (0.5) 137 53 (14) 3.1 (0.7) 140 58 (14)

Adapted from Oostveen E. Eur Respir J 2003; 22: 1026-1041

 Age and Ethnic Variation
Age > 65 Japanese African
American
n 223 166 13
Age (SD) 83 (8) 39 (17) 35 (6)
Rrs (SD) (cmH20/L/s) 2.2 (0.6) M 2.8 (0.5)
2.6 (0.7) F
R5 (SD) (cmH20/L/s) 2.8 (0.7) 3.1 (0.5)
R20 (SD) (cmH20/L/s) 2.4 (0.6) 2.4 (0.4)
R5-R20 (SD) (cmH20/L/s) 0.8 (0.3)
AX (SD) (cmH20/L/s) 4.8 (2.1)
Guo YF et al. Eur Respir J 2005; 26: 602-608
Shitoa S et a. Respirology 2005; 10: 310-315
Haymore BR et al. Am J Respir Crit Care Med 2005; 2: A32
 Which Small Airways?
• Airflow obstruction in COPD correlates to
pathologic airway changes (< 2 mm)
• “Small airway resistance” using FOT
– Airway resistance
– Tissue impedance
• Respiratory compliance
• Tissue resistance
• Concomitant lung volume measurements
may aid physiologic interpretation
Hogg JC. N Engl J Med 2004; 350: 2645-2653
Marchal F. Eur Respir J 1996; 9: 253-261
 Conclusions

• Promising tool in pulmonary testing

• Minimal cooperation, no maneuvers
• Unique tool to evaluate central airways
• Sensitive to peripheral airway changes
and respiratory mechanics
• Further standardization is needed
The Future of Pulmonary
Function Testing?
 COPD and Plethysmography
• Increased interest in
inspiratory capacity
• Indirect measurement
of small airways
• Influenced by
– Patient effort
– Respiratory muscle
strength

Gibson GJ. Clin Chest Med 2001; 22(4): 623-635

Sutherland RE et al. NEJM 2004; 350: 2689-97