A study of artifacts and their removal during forced oscillation of the respiratory system

Self-reported exercise-induced dyspnea and airways obstruction assessed by oscillometry and spirometry in adolescents

BACKGROUND

Self-reported exercise-induced dyspnea (EID) is common among adolescents. Possible underlying pathologies are exercise-induced bronchoconstriction (EIB) and laryngeal obstruction (EILO). The forced oscillation technique (FOT) may evaluate exercise-induced changes in airway caliber.

AIM

To investigate in adolescents the relationship between EID, EIB (post-exercise fall in forced expiratory volume in 1s (FEV₁ )≥10%), EILO, and post-exercise challenge changes in FOT parameters.

METHODS

One hundred and forty-three subjects (97 with EID) of 13-15 years old underwent a standardized exercise challenge with FOT measurement and spirometry repeatedly performed between 2 and 30 min post-exercise. EILO was studied in a subset of 123 adolescents. Subjects showing greater changes than the healthy subgroup in the modulus of the inspiratory impedance were considered FOT responders.

RESULTS

EID-nonEIB subjects presented similar post-exercise changes in all FOT parameters to nonEID-nonEIB adolescents. Changes in all FOT parameters correlated with FEV₁ fall. 45 of 97 EID subjects responded neither by FEV₁ nor FOT to exercise. 19 and 18 subjects responded only by FEV₁ (onlyFEV₁ responders) or FOT (onlyFOTresponders), respectively. Only a lower baseline forced vital capacity (FVC)%predicted and a higher FEV₁ /FVC distinguished the onlyFEV₁ responders from onlyFOTresponders. FOT parameters did not present specific post-exercise patterns in EILO subjects.

CONCLUSION

FOT can be used to identify post-exercise changes in lower airway function. However, EID has a modest relation with both FEV₁ and FOT responses, highlighting the need for objective testing. More research is needed to understand whether onlyFEV₁ responders and onlyFOTresponders represent different endotypes.

Artificial intelligence for quality control of oscillometry measures

BACKGROUND

The forced oscillation technique (FOT) allows non-invasive lung function testing during quiet breathing even without expert guidance. However, it still relies on an operator for excluding breaths with artefacts such as swallowing, glottis closure and coughing. This manual selection is operator-dependent and time-consuming. We evaluated supervised machine learning methods to exclude breaths with artefacts from data analysis automatically.

METHODS

We collected 932 FOT measurements (Resmon Pro Full, Restech) from 155 patients (6-87 years) following the European Respiratory Society (ERS) technical standards. Patients were randomly assigned to either a training (70%) or test set. For each breath, we computed 71 features (including anthropometric, pressure stimulus, breathing pattern, and oscillometry data). Univariate filter, multivariate filter and wrapper methods for feature selection combined with several classification models were considered.

RESULTS

Trained operators identified 4333 breaths with- and 10244 without artefacts. Features selection performed by a wrapper method combined with an AdaBoost tree model provided the best performance metrics on the test set: Balanced Accuracy = 85%; Sensitivity = 79%; Specificity = 91%; AUC-ROC = 0.93. Differences in FOT parameters computed after manual or automatic breath selection was less than ∼0.25 cmH₂O*s/L for 95% of cases.

CONCLUSION

Supervised machine-learning techniques allow reliable artefact detection in FOT diagnostic tests. Automating this process is fundamental for enabling FOT for home monitoring, telemedicine, and point-of-care diagnostic applications and opens new scenarios for respiratory and community medicine.

Technical standards for respiratory oscillometry

Oscillometry (also known as the forced oscillation technique) measures the mechanical properties of the respiratory system (upper and intrathoracic airways, lung tissue and chest wall) during quiet tidal breathing, by the application of an oscillating pressure signal (input or forcing signal), most commonly at the mouth. With increased clinical and research use, it is critical that all technical details of the hardware design, signal processing and analyses, and testing protocols are transparent and clearly reported to allow standardisation, comparison and replication of clinical and research studies. Because of this need, an update of the 2003 European Respiratory Society (ERS) technical standards document was produced by an ERS task force of experts who are active in clinical oscillometry research.The aim of the task force was to provide technical recommendations regarding oscillometry measurement including hardware, software, testing protocols and quality control.The main changes in this update, compared with the 2003 ERS task force document are 1) new quality control procedures which reflect use of "within-breath" analysis, and methods of handling artefacts; 2) recommendation to disclose signal processing, quality control, artefact handling and breathing protocols (e.g. number and duration of acquisitions) in reports and publications to allow comparability and replication between devices and laboratories; 3) a summary review of new data to support threshold values for bronchodilator and bronchial challenge tests; and 4) updated list of predicted impedance values in adults and children.

Reactance and elastance as measures of small airways response to bronchodilator in asthma

Bronchodilation alters both respiratory system resistance (Rrs) and reactance (Xrs) in asthma, but how changes in Rrs and Xrs compare, and respond differently in health and asthma, in reflecting the contributions from the large and small airways has not been assessed. We assessed reversibility using spirometry and oscillometry in healthy and asthma subjects. Using a multibranch airway-tree model with the mechanics of upper airway shunt, we compared the effects of airway dilation and small airways recruitment to explain the changes in Rrs and Xrs. Bronchodilator decreased Rrs by 23.0 (19.0)% in 18 asthma subjects and by 13.5 (19.5)% in 18 healthy subjects. Estimated respiratory system elastance (Ers) decreased by 23.2 (21.4)% in asthma, with no significant decrease in healthy subjects. With the use of the model, airway recruitment of 15% across a generation of the small airways could explain the changes in Ers in asthma with no recruitment in healthy subjects. In asthma, recruitment accounted for 40% of the changes in Rrs, with the remaining explained by airway dilation of 6.8% attributable largely to the central airways. Interestingly, the same dilation magnitude explained the changes in Rrs in healthy subjects. Shunt only affected Rrs of the model. Ers was unaltered in health and unaffected by shunt in both groups. In asthma, Ers changed comparably to Rrs and could be attributed to small airways, while the change in Rrs was split between large and small airways. This implies that in asthma Ers sensed through Xrs may be a more effective measure of small airways obstruction and recruitment than Rrs.NEW & NOTEWORTHY This is the first study to quantify to relative contributions of small and large airways to bronchodilator response in healthy subjects and patients with asthma. The response of the central airways to bronchodilator was similar in magnitude in both study groups, whereas the response of the small airways was significant among patients with asthma. These results suggest that low-frequency reactance and derived elastance are both sensitive measures of small airway function in asthma.

Comparison of a micro-electro-mechanical system airflow sensor with the pneumotach in the forced oscillation technique

Purpose

This study supports the use of thin-film micro-electro-mechanical system (MEMS) airflow sensors in the forced oscillation technique.

Materials and methods

The study employed static testing using air flow standards and computer-controlled sound attenuations at 8 Hz. Human feasibility studies were conducted with a testing apparatus consisting of a pneumotach and thin-film MEMS air flow sensors in series. Short-time Fourier transform spectra were obtained using SIGVIEW software.

Results

Three tests were performed, and excellent correlations were observed between the probes. The thin-film MEMS probe showed superior sensitivity to higher frequencies up to 200 Hz.

Conclusion

The results suggest that lower-cost thin-film MEMS can be used for forced oscillation technique applications (including home care devices) that will benefit patients suffering from pulmonary diseases such as asthma, COPD, and cystic fibrosis.

Automated quality control of forced oscillation measurements: respiratory artifact detection with advanced feature extraction

The forced oscillation technique (FOT) can provide unique and clinically relevant lung function information with little cooperation with subjects. However, FOT has higher variability than spirometry, possibly because strategies for quality control and reducing artifacts in FOT measurements have yet to be standardized or validated. Many quality control procedures rely on either simple statistical filters or subjective evaluation by a human operator. In this study, we propose an automated artifact removal approach based on the resistance against flow profile, applied to complete breaths. We report results obtained from data recorded from children and adults, with and without asthma. Our proposed method has 76% agreement with a human operator for the adult data set and 79% for the pediatric data set. Furthermore, we assessed the variability of respiratory resistance measured by FOT using within-session variation (wCV) and between-session variation (bCV). In the asthmatic adults test data set, our method was again similar to that of the manual operator for wCV (6.5 vs. 6.9%) and significantly improved bCV (8.2 vs. 8.9%). Our combined automated breath removal approach based on advanced feature extraction offers better or equivalent quality control of FOT measurements compared with an expert operator and computationally more intensive methods in terms of accuracy and reducing intrasubject variability.NEW & NOTEWORTHY The forced oscillation technique (FOT) is gaining wider acceptance for clinical testing; however, strategies for quality control are still highly variable and require a high level of subjectivity. We propose an automated, complete breath approach for removal of respiratory artifacts from FOT measurements, using feature extraction and an interquartile range filter. Our approach offers better or equivalent performance compared with an expert operator, in terms of accuracy and reducing intrasubject variability.

Reference values of impulse oscillometric lung function indices in adults of advanced age

Background

Impulse oscillometry (IOS) is a non-demanding lung function test. Its diagnostic use may be particularly useful in patients of advanced age with physical or mental limitations unable to perform spirometry. Only few reference equations are available for Caucasians, none of them covering the old age. Here, we provide reference equations up to advanced age and compare them with currently available equations.

Methods

IOS was performed in a population-based sample of 1990 subjects, aged 45–91 years, from KORA cohorts (Augsburg, Germany). From those, 397 never-smoking, lung healthy subjects with normal spirometry were identified and sex-specific quantile regression models with age, height and body weight as predictors for respiratory system impedance, resistance, reactance, and other parameters of IOS applied.

Results

Women (n = 243) showed higher resistance values than men (n = 154), while reactance at low frequencies (up to 20 Hz) was lower (p<0.05). A significant age dependency was observed for the difference between resistance values at 5 Hz and 20 Hz (R5–R20), the integrated area of low-frequency reactance (AX), and resonant frequency (Fres) in both sexes whereas reactance at 5 Hz (X5) was age dependent only in females. In the healthy subjects (n = 397), mean differences between observed values and predictions for resistance (5 Hz and 20 Hz) and reactance (5 Hz) ranged between −1% and 5% when using the present model. In contrast, differences based on the currently applied equations (Vogel & Smidt 1994) ranged between −34% and 76%. Regarding our equations the indices were beyond the limits of normal in 8.1% to 18.6% of the entire KORA cohort (n = 1990), and in 0.7% to 9.4% with the currently applied equations.

Conclusions

Our study provides up-to-date reference equations for IOS in Caucasians aged 45 to 85 years. We suggest the use of the present equations particularly in advanced age in order to detect airway dysfunction.