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Impulse OscillometryImpulse Oscillometry: Uses and Applications: Interpretation and Practical Applications FREE TO VIEW

Scott Bickel, MD; Jonathan Popler, MD, FCCP; Burton Lesnick, MD, FCCP; Nemr Eid, MD, FCCP
Author and Funding Information

From the Department of Pediatrics (Drs Bickel and Eid), University of Louisville, Louisville, KY, and Georgia Pediatric Pulmonology 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


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(3):841-847. doi:10.1378/chest.13-1875
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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 function 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 bronchoprovocation 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.

Figures in this Article

Pulmonary function testing is used to evaluate respiratory mechanics and physiology in both children and adults with suspected respiratory diseases. Spirometry is perhaps the most commonly used pulmonary function test with the advantage of being readily available in both inpatient and outpatient settings, including many primary care offices. Lung volume measurement by body plethysmography or gas dilution requires more-expensive equipment that often requires a dedicated pulmonary function testing laboratory. Simple spirometry and body plethysmography often can be performed successfully in children but may be limited by the child’s ability to follow directions and provide maximal, reproducible efforts. Some of the challenges in performing spirometry in younger children, especially those aged 2 to 5 years, may have led to this diagnostic modality being significantly underused.1,2 Current data suggest that only 21% of primary care practitioners use spirometry in the diagnosis of asthma in children.3

Impulse oscillometry (IOS) is an effort-independent modality based on the well-described forced oscillation technique4,5 and has emerged as a method to measure pulmonary function in both preschool- and school-aged children in whom reliable spirometry is difficult to obtain.6 Similarly, adults with both physical and cognitive limitations may benefit from this methodology.7 This article reviews the clinical use of IOS, potential limitations, and appropriate coding practices for the clinician.

IOS is a simple, noninvasive method requiring only passive patient cooperation that allows for the evaluation of lung function through the measurement of both airway resistance and airway reactance.1,8 Current IOS procedures are based on the physiologic concepts of the forced oscillation technique originally described by Dubois et al4 in 1956. IOS uses sound waves to rapidly detect airway changes and requires only normal tidal breathing from the patient. Pulmonary mechanics are determined by superimposing small external pressure signals on the spontaneous breaths of the patient. When analyzed, these pressure signals separately quantify the degree of obstruction in the central and peripheral airways. Forced oscillation works by having a loudspeaker generate harmonic sound waves that flow through a conduit tube and mouthpiece into the respiratory tract of the patient. In forced oscillometry, these sound waves can be of single or multiple frequencies, which usually range from between 2 and 4 Hz to between 30 and 35 Hz.9,10 IOS is a form of the forced oscillation technique in which the pressure oscillations are applied at a fixed (square wave) frequency of 5 Hz and from which all other frequencies of interest are derived.8 Pressure and flow transducers measure amplitude and phase differences to determine the impedance of the respiratory system.

The impulses generated by the loudspeaker travel superimposed on normal tidal breathing through the large and small airways, with higher frequencies reflecting back from the large airways to the mouth and lower frequencies traveling deeper into the lung before returning. A pressure and flow transducer measures inspiratory and expiratory flow and pressure. The resultant signals of pressure and flow are separated from the breathing pattern by signal filtering. Respiratory impedance is the sum of all the forces (resistance and reactance) opposing the pressure impulses (oscillations) and is calculated from the ratio of pressure and flow at each frequency.9,10

Interpreting IOS results requires one to be familiar with the specific attributes of the test. Resistance is the in-phase component of lung impedance and reflects information about the forward pressure of the conducting airways, whereas the reactance is the out-of-phase component of lung impedance and reflects the capacitive and inertive properties of the airways. Capacitance can be thought of as reflecting the elasticity of the airway, whereas inertance reflects the mass-inertive forces of the moving air column.10 Reactance can be viewed as the rebound resistance, or an echo, giving information about the distensible airways.4,10 At low frequencies, capacitive pressure loss is large compared with inertive pressure loss, whereas at higher frequencies, the inertive properties dominate. Therefore, the reactance at 5 Hz (X5) reflects the combined effect of tissue elastance and inertance, although at this lower frequency, the effect of tissue elastance would dominate. Because the ability of the lungs to store capacitive energy is primarily manifest in the small airways, reactance at low frequencies can provide important information about the distal airways. Although the mathematical model behind resistance and reactance has been described in detail elsewhere9,11,12 and is beyond the scope of this article, it is helpful to understand that inertance represents a positive value and capacitance a negative value. States that reduce the elasticity of the lung, such as fibrosis and hyperinflation, make capacitance increasingly negative.10

The intermediate frequency at which the total reactance is null is known as the resonant frequency (Fres) and is illustrated by a sample IOS result in Figure 1. The Fres occurs when the magnitudes of the capacitive and inertive pressure loss are the same. This value can be of use in discriminating between low-frequency and high-frequency reactance values: Below the Fres, the elastic properties of the lung (represented by capacitance) dominates, whereas above the Fres, inertance dominates.10 The Fres tends to be higher in children, to decrease with age, and to be elevated in both restrictive and obstructive states.

Figure Jump LinkFigure 1  Sample impulse oscillometry result illustrating key impulse oscillometry attributes. F = frequency; R5 = resistance at 5 Hz; R20 = resistance at 20 Hz; X5 = reactance at 5 Hz.Grahic Jump Location

The area of reactance (AX) is another common parameter used in interpreting IOS. AX represents the total reactance (area under the curve) at all frequencies between 5 Hz and Fres (Fig 1).10,13 This single value, therefore, comprises all the frequencies measured by IOS where the elastic properties of the lung (again, represented by capacitance) dominates over inertance. As with X5, this value also provides information regarding peripheral airway obstruction.

The resistance at 5 Hz (R5) represents the total airway resistance, and the resistance at 20 Hz (R20) represents the resistance of the large airways. One can infer the resistance of the small airways by subtracting R20 from R5, which can be used with X5, Fres, and AX to reflect changes in the degree of obstruction in the peripheral airways. Airway resistance decreases with age. In patients with small airways disease, changes in resistance at low frequencies (R5) become apparent.3,13

Coherence is an important IOS parameter for the practitioner to recognize and review in interpreting the validity of IOS results. Coherence, a value between 0 and 1, reflects the reproducibility of impedance measurements and is based on a comparison between the airflow entering the lungs and the pressure wave reflected back from the respiratory system.8 To ensure accurate testing, coherence at 5 Hz should ideally be > 0.8 cm H2O, with coherence at 20 Hz between 0.9 and 1.6,14 Coherence is decreased by improper technique, swallowing, glottis closure, obstruction of airflow by the tongue, or irregular breathing.8 It is important to note that coherence cutoff values have not been validated in younger children.8,15

IOS can be performed in an inpatient or outpatient setting. The device should be calibrated daily as directed by the manufacturer.15 IOS is typically performed with the patient sitting and breathing at tidal volume, the head held in neutral position, a nose clip in place, and the cheeks firmly supported by either the patient or another individual such as the examiner or caregiver.9 This positioning is important to limit the influence of the compliance of the cheeks and prevent shunting of the applied impulses through the upper airway.9,16 The maneuver should also be performed with the legs uncrossed to reduce extraneous intrathoracic pressure.8 The procedure takes approximately 20 to 90 s to complete.

Because IOS does not require the forced expiratory maneuvers needed to generate spirometric data, it can be easily used in the pediatric population17,18 and in adults who may be too weak or otherwise unable to perform spirometry. IOS may also be useful where spirometry is contraindicated, such as in patients who recently underwent surgery or who have had recurrent pneumothoraces or in cases where spirometry-related bronchospasm is a concern.17 IOS has been used in both adult and pediatric patients for the diagnosis of airway hyperreactivity and airway obstruction14,19 and may be used during bronchoprovocation challenges.20 As with spirometry, IOS values are correlated with clinical symptoms and asthma control,18 although an advantage of IOS may be the detection of subtle changes in a patient’s airway function earlier than with conventional spirometry.17,21 Some data suggest that IOS can be used to assess abnormal distal airway function, even in the setting of normal spirometry.21,22 Indeed, Shi et al13 found that neither forced expiratory flow, midexpiratory phase (FEF25%-75%) nor FEV1 was as effective as small airway IOS indexes in detecting poorly controlled asthma in children.

IOS has been studied in a number of disease states, including asthma, COPD,23 cystic fibrosis,2426 bronchopulmonary dysplasia (BPD),27 OSA,28,29 central airway obstruction,30 adult interstitial lung disease,31 and occupational and environmental irritant exposure.21,32 IOS has been found to be useful in measuring response to bronchodilators, such as salbutamol and ipratropium, in patients with asthma and COPD.3335

The American Thoracic Society (ATS) recently released a statement summarizing optimal pulmonary function tests in children age < 6 years.36 Regarding cystic fibrosis and IOS, the ATS noted limited data, with recent studies not demonstrating a change in airway resistance or reactance in young children.25 Studies thus far have been unable to establish an association between IOS parameters and ongoing infections or increased coughing.2426

The forced oscillation technique has been used for several decades in patients with BPD.27 The ATS36 noted one study indicating that children with a history of BPD have elevated resistance, decreased reactance, and higher Fres.37 Udomittipong et al38 demonstrated in a multivariate analysis that a significant relationship exists between length of oxygen requirement and a patient’s IOS parameters.

Although studied in other disease states, IOS has perhaps been best characterized to date for its use in asthma. Studies have demonstrated that patients with asthma have an elevated R5,3941 an elevated AX,39,41 an elevated Fres,39,41 and a more negative X53941 compared with control subjects. Additionally, improvement in airway resistance after bronchodilator administration appears to correlate well with a bronchodilator response by standard spirometry.40 When using IOS to assess a patient with asthma, one should look at multiple parameters. A change in R5 by 30% to 35% has been found to reflect a positive response to bronchodilators.14,42 Komarow et al17 reported that resistance at 10 Hz (R10) and AX had the best profiles based on the receiver operating characteristic for detecting a significant bronchodilator response. A −8.6% change in R10 and a −29.1% change in AX were reported as the optimal cutoff points.

IOS has also been used in bronchoprovocation testing. A typical response will show an increase in R5, R20, and Fres with a decrease in X5.43 Bailly et al43 reported that X5 was the only parameter sensitive enough to detect bronchial hyperreactivity and that a 20% decline in FEV1 correlated with a 50% decrease in X5. Other studies have reported similar findings,44,45 whereas Vink et al46 also demonstrated a correlation between decreased FEV1 and increased R5 and R10. When used with IOS, lower doses of bronchoprovocative agents are required to induce measurable and significant bronchoconstriction.47,48 Indeed, Schulze et al49 showed significant increases in resistance well before a response was seen in FEV1 at lower doses of methacholine, suggesting that oscillation techniques are more sensitive than spirometry.

One area of difficulty in the management of pediatric asthma is the prediction of loss of disease control.50 Some pediatric patients may have difficulty verbalizing respiratory symptoms, whereas others may have difficulty perceiving a change in their respiratory status.51 Objective parameters to predict loss of asthma control, including traditional spirometry and exhaled nitric oxide levels, do not appear to accurately reflect a decline in asthma control.5254 In a recent study, Shi et al50 demonstrated that children with controlled asthma who have increased peripheral airway IOS indexes are at risk for losing asthma control, which suggests that monitoring small airway function by IOS can be useful in identifying patients who are at risk for losing asthma control and in assisting with clinical decisions and treatment plans. Regarding treatment strategies, Rabinovitch et al55 recently published data correlating elevated AX with positive response to combined long-acting β-agonist therapy vs increasing the dosage of inhaled corticosteroids, although the exact reasoning behind the association remains unclear and further research is needed. These reports add to existing data emphasizing the importance of the small airways in asthma control.20,22

Clinical applications of IOS may best be illustrated by reviewing case examples based on actual patients evaluated in a pediatric pulmonary clinic. The first case is that of a 6-year-old girl who presented with a chronic cough of several years. She had normal spirometry (FEV1, 114%; FEF25%-75%, 79%) without significant change to bronchodilators. IOS in this patient showed normal R5 and R20 but elevated AX (26.97 cm H2O/L) and depressed X5 (−3.7597 cm H2O/L/s, 130% of normal). She also demonstrated a positive response to bronchodilators, with a −44.5% change in AX and a −39% change in X5 (Fig 2). The patient was, therefore, started on inhaled corticosteroids to control her symptoms, and she demonstrated good clinical improvement.

Figure Jump LinkFigure 2  Impulse oscillometry results in a 6-y-old girl with chronic cough and normal spirometry. Chg = change; CO = coherence; pred = predicted; R = resistance; X = reactance. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location

Another patient seen in the same clinic was a 9-year-old boy with a history of corrected double aortic arch, residual tracheomalacia, and suspected persistent asthma. He had persistently abnormal spirometry (baseline FEV1, approximately 60%, FEF25%-75%, approximately 40%), with flow-volume loops consistent with intrathoracic obstruction. These persistent abnormalities made objective assessment of his underlying, coexistent asthma difficult. Thus, the patient underwent IOS, which showed normal values (R5, 113%; R20, 78%), except for a mildly decreased X5 (−3.25 cm H2O/L/s, 137% of normal), without significant response to bronchodilators in any parameter (Fig 3). As a result, the patient was able to be weaned successfully from high-dose combined inhaled corticosteroids and long-acting β-agonists.

Figure Jump LinkFigure 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.Grahic Jump Location

Although IOS has many useful clinical applications, the procedure has some limitations. First, the procedure is effort-independent compared with spirometry, but patients still need to be cooperative to generate valid results. Second, spirometry is currently more widely adopted and better studied15,35,36; therefore, interpretation of its results often are more straightforward to the practitioner. Research remains ongoing about the precise meaning, interpretation, and clinical application of IOS parameters, especially in less common disease states such as childhood interstitial lung disease or in settings such as the ICU where the forced oscillation technique may have applications for sedated patients15 or those receiving ventilation.56 Furthermore, the ATS noted that reference values for IOS are primarily available for non-Hispanic white children,36 although data from other populations are becoming available.7,5760 As discussed, IOS is well suited for conditions involving airway obstruction, but it may not provide definitive information on restrictive states,9 although more research into this area is needed.

For US practitioners, IOS can be billed using Current Procedural Terminology code 94728. At present, the Centers for Medicare & Medicaid Services assigns 0.26 physician work relative value units for interpretation of IOS. If the physician is only doing the interpretation and does not own the equipment, a -26 modifier is used. When performed in a nonfacility, the global reimbursement is 1.35 relative value units, including both the technical component and the physician interpretation. In general, a -25 modifier should be appended to the evaluation and management code when performed on the same day of service. It should also be noted that most payers consider IOS to be for patients who are unable to perform spirometry, although there are clinical situations as discussed herein where the two tests may be complementary. For this reason, IOS is not generally billable on the same day as spirometry or other pulmonary function tests.

IOS is a useful tool in the diagnosis and evaluation of pediatric and adult patients with asthma and obstructive lung diseases. IOS can be performed easily in children aged < 5 years, making it useful in children unable to perform traditional spirometry. IOS may be more sensitive than spirometry at identifying pathology in the peripheral airways and may have better predictive value than spirometry in identifying patients with potential loss of asthma control. IOS allows bronchoprovocation testing at lower doses of methacholine. Research is ongoing regarding the utility of IOS in other pulmonary conditions.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

ATS

American Thoracic Society

AX

area of reactance

BPD

bronchopulmonary dysplasia

FEF25%-75%

forced expiratory flow, midexpiratory phase

Fres

resonant frequency

IOS

impulse oscillometry

R5

resistance at 5 Hz

R10

resistance at 10 Hz

R20

resistance at 20 Hz

X5

reactance at 5 Hz

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Shi Y, Aledia AS, Galant SP, George SC. Peripheral airway impairment measured by oscillometry predicts loss of asthma control in children. J Allergy Clin Immunol. 2013;131(3):718-723. [CrossRef] [PubMed]
 
Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/adolescent asthma: the Room to Breathe survey. Eur Respir J. 2012;39(1):90-96. [CrossRef] [PubMed]
 
Cabral AL, Vollmer WM, Barbirotto RM, Martins MA. Exhaled nitric oxide as a predictor of exacerbation in children with moderate-to-severe asthma: a prospective, 5-month study. Ann Allergy Asthma Immunol. 2009;103(3):206-211. [CrossRef] [PubMed]
 
Farah CS, King GG, Brown NJ, et al. The role of the small airways in the clinical expression of asthma in adults. J Allergy Clin Immunol. 2012;129(2):381-387. [CrossRef] [PubMed]
 
Farah CS, King GG, Brown NJ, Peters MJ, Berend N, Salome CM. Ventilation heterogeneity predicts asthma control in adults following inhaled corticosteroid dose titration. J Allergy Clin Immunol. 2012;130(1):61-68. [CrossRef] [PubMed]
 
Rabinovitch N, Mauger DT, Reisdorph N, et al. Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma. J Allergy Clin Immunol. 2014;133(2):350-356. [CrossRef] [PubMed]
 
Farré R, Mancini M, Rotger M, Ferrer M, Roca J, Navajas D. Oscillatory resistance measured during noninvasive proportional assist ventilation. Am J Respir Crit Care Med. 2001;164(5):790-794. [CrossRef] [PubMed]
 
Park JH, Yoon JW, Shin YH, et al. Reference values for respiratory system impedance using impulse oscillometry in healthy preschool children. Korean J Pediatr. 2011;54(2):64-68. [CrossRef] [PubMed]
 
Lee JY, Seo JH, Kim HY, et al. Reference values of impulse oscillometry and its utility in the diagnosis of asthma in young Korean children. J Asthma. 2012;49(8):811-816. [CrossRef] [PubMed]
 
Calogero C, Simpson SJ, Lombardi E, et al. Respiratory impedance and bronchodilator responsiveness in healthy children aged 2-13 years. Pediatr Pulmonol. 2013;48(7):707-715. [CrossRef] [PubMed]
 
Oostveen E, Boda K, van der Grinten CP, et al. Respiratory impedance in healthy subjects: baseline values and bronchodilator response. Eur Respir J. 2013;42(6):1513-1523. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1  Sample impulse oscillometry result illustrating key impulse oscillometry attributes. F = frequency; R5 = resistance at 5 Hz; R20 = resistance at 20 Hz; X5 = reactance at 5 Hz.Grahic Jump Location
Figure Jump LinkFigure 2  Impulse oscillometry results in a 6-y-old girl with chronic cough and normal spirometry. Chg = change; CO = coherence; pred = predicted; R = resistance; X = reactance. See Figure 1 legend for expansion of other abbreviations.Grahic Jump Location
Figure Jump LinkFigure 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.Grahic Jump Location

Tables

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Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/adolescent asthma: the Room to Breathe survey. Eur Respir J. 2012;39(1):90-96. [CrossRef] [PubMed]
 
Cabral AL, Vollmer WM, Barbirotto RM, Martins MA. Exhaled nitric oxide as a predictor of exacerbation in children with moderate-to-severe asthma: a prospective, 5-month study. Ann Allergy Asthma Immunol. 2009;103(3):206-211. [CrossRef] [PubMed]
 
Farah CS, King GG, Brown NJ, et al. The role of the small airways in the clinical expression of asthma in adults. J Allergy Clin Immunol. 2012;129(2):381-387. [CrossRef] [PubMed]
 
Farah CS, King GG, Brown NJ, Peters MJ, Berend N, Salome CM. Ventilation heterogeneity predicts asthma control in adults following inhaled corticosteroid dose titration. J Allergy Clin Immunol. 2012;130(1):61-68. [CrossRef] [PubMed]
 
Rabinovitch N, Mauger DT, Reisdorph N, et al. Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma. J Allergy Clin Immunol. 2014;133(2):350-356. [CrossRef] [PubMed]
 
Farré R, Mancini M, Rotger M, Ferrer M, Roca J, Navajas D. Oscillatory resistance measured during noninvasive proportional assist ventilation. Am J Respir Crit Care Med. 2001;164(5):790-794. [CrossRef] [PubMed]
 
Park JH, Yoon JW, Shin YH, et al. Reference values for respiratory system impedance using impulse oscillometry in healthy preschool children. Korean J Pediatr. 2011;54(2):64-68. [CrossRef] [PubMed]
 
Lee JY, Seo JH, Kim HY, et al. Reference values of impulse oscillometry and its utility in the diagnosis of asthma in young Korean children. J Asthma. 2012;49(8):811-816. [CrossRef] [PubMed]
 
Calogero C, Simpson SJ, Lombardi E, et al. Respiratory impedance and bronchodilator responsiveness in healthy children aged 2-13 years. Pediatr Pulmonol. 2013;48(7):707-715. [CrossRef] [PubMed]
 
Oostveen E, Boda K, van der Grinten CP, et al. Respiratory impedance in healthy subjects: baseline values and bronchodilator response. Eur Respir J. 2013;42(6):1513-1523. [CrossRef] [PubMed]
 
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