IOSbasic 9 e 1

Impulse Oscillometry (IOS)
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
Page
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
IOSbasic9e1.pmd
02 - 2006 Smith
20
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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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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 (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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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
IOSbasic9e1.pmd
02 - 2006 Smith / ios3rrfe.p65
10
20
30
40 F [Hz]
Page
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]
Page
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]
Page
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
Page
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
Typical example
Proximal obstruction (central)

abnormal
normal

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.
Structural parameters of the Mead model
Rc
or
Ers
Flow/volume
The expiratory portion of the curve
is clearly concave.
Rp
volume
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
Typical example
Distal obstruction (peripheral)
abnormal
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.
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
relationship.
In case of distal obstruction Rp is larger in
shape compared to Rc.
Ers has no clinical relevance.
IOSbasic9e1.pmd
02 - 2006 Smith

X5.
Page 12
Typical example
Pulmonary restriction
abnormal

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.
Rc
Ers
Flow/volume
The curve is of normal shape,
however Vital Capacity VC is
considerably reduced.
Rp
volume
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.
X5.
IOSbasic9e1.pmd
02 - 2006 Smith
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13
Typical example
Extra thoracic airway obstruction

peak

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.
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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14
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
Page
15
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

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
Page
16
4. Assessment of bronchial hyperreactivity (Dilatation)
R5
Fres

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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17
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
!
Page
18
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
Page
19
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.
IOSbasic9e1.pmd
02 - 2006 Smith
Page
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Impulse Oscillometry (IOS)

Impulse Oscillometry (IOS)

Impulse Oscillometry (IOS) - principle

Normal lung function

Proximal obstruction (central)

Distal obstruction (peripheral)

Extra thoracic airway obstruction

General recommendations for the measurement

Forced spirometry report

Impulse Oscillometry report

Oscillometry in comparison to conventional techniques

IOS with proven spirometry / flow/volume application

Features of Impulse Oscillometry

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

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

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

Sensitive determination of obstruction.

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

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

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

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

Impulse test signal provides extreme broad spectrum of frequencies

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

High resolution with maximal 10 measurements per second.

Specific information in combination with spirometry, occlusion and diffusion but

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

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

A further differentiation between distal obstruction and distal restriction is only

V'm = V'r & V'g

P, V' time trend

Derived from negative range of reactance

P, V' time trend

Derived from positive range of reactance

P, V' time trend

Resistance R (Energy Consumption)

Reactance X (Capacitive-inertial storage of energy)

X5 Distal capacitive reactance

The ability to store energy in the capacitance

Resistance spectrum R(f)

Reactance spectrum X(f)

Degree of airway obstruction according to

Resistance spectrum R(f)

Reactance spectrum X(f)

Degree of obstruction according to R5 and

Resistance spectrum R(f)

Reactance spectrum X(f)

Degree of obstruction according to R5 and

Resistance spectrum R(f)

Reactance spectrum X(f)

Resistance spectrum R(f)

Reactance spectrum X(f)