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Diperkirakan tambahan 100 juta penderita asma pada tahun 2025.¹⁾

10 % anak-anak

75 %

Mengalami

gangguan kinerja.²⁾

Tingkat inflamasi dapat ditentukan dengan mengukur NO content saat exhalasi pernafasan

Saat ini belum ada alat pengukur FeNO untuk digunakan di rumah

Worldwide,

sekitar 339 juta orang menderita asma ¹⁾

5 % dewasa ³⁾

Global Asthma Report 2018; ²⁾Civey Survey 2021; ³⁾Lungenärzte im Netz https://www.lungenaerzte-im-netz.de/krankheiten/asthma-bronchiale/haeufigkeit/ ;
⁴⁾“Asthma Health Atlas” of the Scientific Institute of the AOK health insurance fund

⁴⁾

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Asthma

Symptoms & medical background

Asthma adalah :

Inflamasi kronis saluran nafas yang disertai hiper-responsif bronkus yang tidak spesifik dan bervariasi, serta obstruksi jalan nafas yang reversible

70%

Pathophysiology

 Inflamasi saluran pernafasan oleh mast cells, eosinophilic granulocytes and T-lymphocytes

 Hiper-responsive saluran pernafasan

 Terdapat perubahan jaringan saluran pernafasan (endobronchial obstruction)

Penyebab

Asma

bronchiale

Allergic (extrinsic) 231Jt

30%

Non-llergic (intrinsic) 99 Jt

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Nitric Oxide

Model pengaturan NO dalam paru-paru

exhaled NO merupakan penanda diagnostic inflamasi saluran nafas

AHR = Airway hyperresponsiveness

AP1 = Activator Protein 1

iNOS = Inducible NO synthase

STAT-6 = Signal transducer and activator of transcription 6

IFN = Interferon

IL-4/-13 = Interleukine 4/13

Th2 = T-helper cell type 2

¹Abb. Munakata Allerg Int 2012;61:365-72, ²Alving et al. Eur Respir J 1993;6:1368-70, ³Nijkamp et al. Arch Int Pharmacodyn Ther 1995;329:81-96

 Asma karena alergi cenderung mempunyai konsentrasi NO yang lebih tinggi dalam pernafasan ²

 Konsentrasi NO mencerminkan adanya inflamasi saluran pernafasan ³

 Inflamasi Eosinophilic merupakan elemen kunci patofisiologi asma-alergi³

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Biomarker FeNO

Pengukuran terstandar memastikan reproduktivitas

Nasal concentration

Excluded by counter- pressure closing the velum

Oral cave concentration Bypassed fraction of exhaled breath

Lower airways concentration

Target fraction of exhaled breath

ATS/ERS Am J Respir Crit Care Med 2005;171:912–30;

Horváth et al. Eur Respir J 2017;49:1600965

Proporsi NO dalam ppb (parts per billion) dialirkan secara konstan dari saluran nafas bagian bawah/paru-paru

Mengapa harus secara konstan ?

NO muncul karena inflamasi yang dipicu oleh TH2 dari saluran nafas dan dikeluarkan melalui hembusan nafas.
Difusi ini tergantung aliran dan hanya aliran yang konstan sebagai hasil pengukuran..

Apa maksud dari “fractional” ?

Karena fraksi pertama exhalasi berasal dari rongga mulut, maka ini tidak diperhitungkan dalam pengukuran.
Hanya konsentrasi FeNO fraksi kedua yang berasal dari saluran nafas bawah yang diukur.
Ada 2 mode pengukuran yaitu 10 detik untuk semua usia dan 6 detik hanya untuk anak usia 7-11 tahun (karena lumen yang lebih kecil)

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Biomarker FeNO

Penentuan FeNO tergantung pada aliran udara / flow rate

Recommended flow rate for

fractional exhaled nitric oxide:

50mL/s

Flow rate of exhaled breath [mL/s]

NO concentration [ppb]

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200

180

160

140

120

100

NO (ppb)

Internal Data, BHCS, 2020

Start of

pollen

season

Airway infection

Biomarker FeNO

Kadar FeNO pada infeksi pernafasan dan musim alergi

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Biomarker FeNO

Pengukuran : Interpretasi hasil FeNO ^1,2

•

Poor adherence or inhaler technique

¹ATS recommendations, Dweik et al. Am J Respir Crit Care Med 2011;184:602–15, ²Khatri , S. B., et al. 2021. Use of Fractional Exhaled Nitric Oxide to Guide the Treatment of Asthma: An Official American Thoracic Society Clinical Practice Guideline. American Thoracic Society Assembly on Allergy, Immunology, and Inflammation, 2021, ^*ICS=inhaled Corticosteroids

FeNO

Adults

< 25 ppb

25-50 ppb

> 50 ppb

Children

<20 ppb

20-35 ppb

>35 ppb

Diagnosis

Symptoms present

During past 6+weeks

• Eosinophilic airway

inflammation unlikely.

• Alternative diagnosis.

• Unlikely to benefit from ICS*

• Be cautious

• Evaluate clinical context

• Monitor change in FeNO

over time

• Eosinophilic airway

inflammation present

• Likely to benefit from ICS

Monitoring (in patients with diagnosed asthma)

Symptoms present

Symptoms absent

• Possible

alternative diagnoses

• Unlikely to benefit

from increase in ICS

• Persistent allergen exposure

• Inadequate ICS dose

• Poor adherence

• Steroid resistance

• Persistent allergen exposure

• Inadequate ICS dose

• Steroid resistance

• Risk of exacerbation

• Adequate ICS dose

• Good adherence

• ICS taper

• Adequate ICS dosing

• Good adherence

• Monitor change in FeNO

• ICS withdrawal or dose

reduction may result in relapse

• Poor adherence or inhaler technique

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Biomarker FeNO

The level of FeNO

Respiratory function

Study investigasi pengaruh SLIT (sublingualimmunotherapy) terhadap eosinophil airway inflammation – diukur dengan konsentrasi exhaled NO (FeNO) pada anak-anak ¹

Result:



Level FeNO turun secara signifikan dengan SLIT



Perbaikan significant terhadap score symptom nasal and asthma setelah pengobatan 1 tahun pada grup SLIT

Study design:



Perbaikan lebih jauh pada follow up tahun ke 2 (75 and 80% )dibanding dengan groupkontrol

N= 59 patients with allergic asthma and rhinitis (age: 7 – 18 years)

Experimental group = 34 patients with SLIT + drug therapy

Control group = 25 patients with drug therapy

Measurement at baseline and every follow-up

¹Djuric-Filipovic et al. Clin Mol Allergy 2017; 15:7

Study : Manfaat terhadap monitor SLIT

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Biomarker FeNO

Non-disease-related

FeNO values¹

factors

influencing

duration of approx. 30 min afterwards²

¹Dweik et al. Am J Respir Crit Care Med 2011;184:602–15, ²Silkoff et al. Am J Respir Crit Care Med 1999;159:940-44, ³Dressel et al. Respir Med 2008;102:962-9. ⁴Olin et al. Chest 2006;130:1319-25, ⁵McSharry et al. J Allergy Clin Immunol 2005;116:88-93, ⁶Haccuria et al. J Allergy Clin Immunol 2014;134:554-9, ⁷Jacinto et al. J Breath Res 2015; 9: 036005. ⁸Beier et al. Eur Respir J 2003;22:354-7

Factors increasing FeNO values

 Bronchodilatation²

 FeNO measurement before bronchodilatation

 Increased airway caliber^3,4

 height as a surrogate parameter

 Food and Beverages potentially^1,4

 do not drink or eat before measurement

 Atopy^3,4

 Respiratory tract infections³

 Age^4,7

Factors decreasing FeNO values

 Bronchoconstriction^2,6

 FeNO measurement before Provocation

 Spirometry reduces FeNO values for

 FeNO measurement before Spirometry

 Increased mucus production⁸

 FeNO measurement before Sputum induction

 Smoking⁵

 Gender, female^3,4

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Increasing importance of FeNO in the healthcare system

Recommendation of FeNO in New DE and UK Guidelines

Guidelines

Relevant recommendations regarding FeNO

Revised guideline of the

Deutsche Gesellschaft für

Pneumologie und

Beatmungsmedizin e.V. and

the deutsche Atemwegsliga

points out recently FeNO as a

value adding parameter for in

diagnosis and management

of asthma.

Guideline of British National

Institute for Health and Care

Excellence (NICE)

recommends the FeNO-test for

the diagnosis of asthma and

the monitoring in asthma

management.

DIAGNOSIS

Recommendation of FeNO tests as part of comprehensive algorithm for diagnosis of asthma

in adults, children and adolescents.

MANAGEMENT

FeNO measurement is a significant parameter in longterm management.

Regular control helps to reduce asthma relapse after setting down ICS- therapy.

COST-EFFECTIVE

The health economic model in the NICE guideline concludes that FeNO testing in adults is one of the most cost-effective diagnostic tools.

Asthma: diagnosis and monitoring of

asthma in adults, children and young people. National Guideline Centre. On behalf of: National Institute for Health and Care Excellence. November 2017.

S2k-Leitlinie zur Diagnostik und

Therapie von Patienten mit Asthma.

September 2017.

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APPLICATION

VIVATMO

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MDQ-01.720-03-EBA_Salespartner-Training_Rev07

Sensor technology from Bosch

One part per billon – equivalent to a single blade of grass on an entire soccer field.

Sensor mendeteksi konsentrasi sangat rendah dari biomarker yaitu dalam ppb
1 part per billion / ppb setara dengan selembar rumput kering dalam lapangan sepak bola

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Result of benchmark study

Vivatmo

pro

correlates

excellent

with

CLD

and

Niox Vero

Benchmark Study

n = 106 asthma patients
Alat pembanding :

CLD and Niox Vero

Korn et al. Respiration 2020;99(1):1-8.

BV: Bosch Vivatmo

EC: Chemiluminescence Detector (CLD) (gold standard) CN: Circassia Niox

Conclusion:

Agreement for the entire study population within the therapeutically relevant

range (0- 70 ppb) for all devices

External Benchmark-Study:

 University Mainz

 Measurement vs. CLD Ecophysics and Niox Vero

 Poster on ERS 2018

 Publication in Respiratory Journals

submitted

Niox vs. Vivatmo

CLD vs. Vivatmo

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MDQ-01.720-03-EBA_Salespartner-Training_Rev07

Sensor technology based on Bosch know-how

Pengukuran terpercaya dalam compact design

Correct fraction sampling of breath

Tidak termasuk volume saluran nafas atas
Ergonomic mouthpiece : kenyamanan dan pemakaian secara alami

Disposable

^NO2 ^Sensor

Signal

Innovative measuring module :

Sensor technology pengukur NO₂ sangat spesifik
Terjemahan dan koreksi nilai pengukuran dalam ppb berbasis smart algorithm
NO Regeneration phase membersihkan lapisan sensitive sensor chip untuk pengukuran berikutnya.
Display dan menyimpan hasil

Exhaled NO

NO₂

Sensor technology

measures NO₂with highest specificity

Sample preparation

and conversion of NO to measured equivalent NO₂

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Gambaran proses exhalasi dalam disposable mouthpiece

Mouthpiece canggih, untuk pengukuran sample

Rel. concentration

100 %

Proteksi terhadap cross-contamination
Eliminasi komponen pengganggu dan gas
Konversi NO untuk mengukur

equivalent NO₂

Sample dehumidification

NO₂

Humidity

Interfering species

50 %

0 %

Germ filter

Interference

filter

Converter

Desiccant

Sensor technology based on Bosch know-how

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Vivatmo Me

Technical data

Feature

Product description

Measuring range

5 ppb to 300 ppb

Accuracy

± 5 ppb below 50 ppb, ± 10 % for ≥ 50 ppb, ± 15 % for ≥ 160 ppb

Expressed as the upper confidence limit of 95 %

Lifetime, memory capacity

1,000 measurements

Exhalation Time

10 sec / 6 sec

Operating Time

3 years

Sensor

Chemical field-effect transistor

Display

Digital LCD display

Power source

4 AAA Batteries 1.5 V (Lithium/iron disulfide)

Weight / Dimension

170 g / 4,0 cm x 5,4 cm x 22,4 cm

Package contents

Vivatmo me device, 5 disposable mouthpieces, batteries, protective cap, Instructions for Use

Operating temperature / humidity /

air pressure

+15 °C to +27 °C / 15 % to 60 % relative humidity (non-condensing) / 780 hPa to 1100

hPa (0-2000 m a.s.l)

Storage and transport temperature /

humidity / air pressure

+5 °C to +27 °C / 10 % to 60 % relative humidity /

780 hPa to 1100 hPa

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Vivatmo Me – Package content

Protective

cap

5 disposable

mouthpieces

Handheld

4 AAA cells

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Vivatmo Me

Step pertama penggunaan Vivatmo Me

Pasang 4 baterei AAA dan switch on.

Set tanggal & jam pada saat pertama kali digunakan

Ambil mouth-piece dari kantong dan pasang pada alat

Tekan tombol ENTER untuk memulai proses.

Perlu waktu 1 menit

Melakukan pengukuran

Tarik nafas melalui mulut dan hembuskan secara konstan.
Bila LED menyala : Yellow - terlalu lemah. Blue - sudah benar. Red - terlalu kuat

Hasil

Hasil pengukuran akan muncul di layar
Skala traffic light menunjukkan nilai FeNO
Mouthpiece dilepas dan dibuang dan alat ditutup kembali

Vivatmo Me menunjukkan simbol SIAP digunakan

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MDQ-01.720-03-EBA_Salespartner-Training_Rev07

Vivatmo me

Petunjuk : Penggunaan setelah disimpan

Proses Reconditioning

 Simbol proses reconditioning alat, sekitar 1 menit

 Bila muncul symbol kunci-pas maka secara otomatis alat akan melakukan proses

reconditioning

 Proses reconditioning berlangsung 7 sampai 90 menit dan tidak bisa diinterupsi

 Angka kanan bawah menunjukkan estimasi waktu reconditioning

 Alat akan berbunyi dan berkedip biru 3 kali warna bila reconditioning selesai dan

muncul simbol alat siap untuk digunakan

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Vivatmo me

Error

messages

the package

Display

Description

Solution

Disposable mouthpiece is not valid.

Exchange the mouthpiece and take a new one from

Measurement failed, exhalation

through the device was excessively weak or

strong or the measurement was not

performed within 6 seconds after completed

regeneration process.

Repeat the measurement.

Permissible number of measurements < 20.

See display for number of remaining measurements.

Maximum number of permissible

measurements reached. Device does not

perform any measurements.

Dispose your Vivatmo me.

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Vivatmo me

Error

messages

persists, contact the service.

If the error persists, contact the service.

Display

Description

Solution

Humidity too high.

Check ambient conditions and take a new mouthpiece.

Ambient temperature and air pressure (altitude)

is outside the specified range.

Use the Vivatmo me in location with permissible

ambient conditions. When transporting the device from

one place to another, a stabilization period of min. 20

minutes should be allowed before use.

Batteries are too weak for measurement.

Replace batteries with new ones.

System self-test failed.

Replace batteries with new ones and start again. If the error

Regeneration failed.

Press the ENTER button to repeat the purging.

None – the device will not turn on.

Batteries are empty /

Batteries are inserted the wrong way

Replace batteries with new ones. /

Ensure the batteries are inserted with correct polarity.

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Vivatmo me

Hints:

Battery

type

and

useful

life

Vivatmo me is delivered with 4 AAA Lithium/iron disulfide batteries 1.5 V

Useful life of primary batteries:

Lithium/iron disulfide up to 60 attempts

Alkaline up to 25 attempts

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Vivatmo pro

Performing the measurement maneuver

–

Air

Flow



Concentrate and breathe deep and consciously

Start to blow weakly, then slowly increase the air flow like blowing a party horn without making too much noise

Aim: maintain a constant air flow



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MDQ-01.720-03-EBA_Salespartner-Training_Rev07

Vivatmo Me : Cara melakukan pengukuran FeNO

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114

https://

ekatalog.lkpp.go.id/katalog/produk/detail/66738800?lang=id&type=general

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Brosur Vivatmo

..\Brochure Vivatmo\Brosur Vivatmo Indo 30052023_lipat 3 final.pdf

..\Brochure Vivatmo\200721_BHCS_18302_Vivatmo_Indo_Rev.080523.pdf

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VIVATMO

PRO

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MDQ-01.720-03-EBA_Salespartner-Training_Rev07

Vivatmo Pro – Professional asthma management

Fungsi optimal untuk penggunaan klinis

Unit pengukur wireless

 Dudukan untuk charge baterei

 Power baterei untuk 30 measurements

 Komunikasi, kontrol dan supervisi via Bluetooth Low Energy

Interaksi via Touchscreen

 Tersedia animasi selama proses pengukuran

 Display grafik hasil pengukuran

 Sinkronisasi data dengan unit pengukuran

Data management

 Managemen data pasien dan pengukuran

 Print and export hasil pengukuran

 Terhubung dengan semua interfaces (USB,

Ethernet, WLAN)

 Integrasi dalam IT klinis menggunakan komunikasi

via HL7/GDT

 Tersedia remote update via platform koneksi

Vivasuite

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Vivatmo pro

Tujuan dan indikasi penggunaan

Untuk pengukuran fractional NO pernafasan secara quantitatif
Mengukur perubahan konsentrasi NO pernafasan guna mengevaluasi respon terapi anti-inflamasi pasien asma.
Pasien melakukan exhalasi via disposable mouthpiece. Untuk pasien umur 7 tahun atau lebih tua.
Pengukuran FeNO berdasarkan rekomendasi dari European Respiratory Society (ERS) and the American Thoracic Society (ATS)

ATS 2011 : diagnosis of eosinophilic airway inflammation and in determining the likelihood of responsiveness to anti-inflammatory pharmacological therapy in individuals with chronic respiratory symptoms possibly due to airway inflammation.

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Vivatmo pro

Technical data

Expressed as the upper/lower confidence limit of 95 %

Feature

Description

Operating conditions

+15 °C to +27 °C / 15 % to 60 % relative air humidity (non-condensing) / 780 to 1100 hPa air pressure

Transportation conditions

-20°C to +60 °C for max. 72 hours / ≤ 85 % % relative air humidity for max. 72 hours / 780 to 1100 hPa air pressure

Storage conditions

+5 °C to +27 °C / 10 % to 60 % relative air humidity between uses / 780 to 1100 hPa air pressure

Operating Time

5 years

BASESTATION

Display

7 inch 16:10, 1024 x 600 pixel touchscreen

Weight / Dimensions

1350 g / 265 x 213 x 160 mm

HANDHELD

Measurement range

5 ppb to 300 ppb

Lifetime

At least 5,000 measurement trials

Exhalation time

10 sec / 6 sec

Sensor

Chemical field-effect transistor

Accuracy

± 5 ppb below 50 ppb, ± 10 % for ≥ 50 ppb, ± 15 % for ≥ 160 ppb

Power supply

1 Lithium-ion rechargeable battery

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Vivatmo Pro – package content

Device and power supply

Handheld

Rechargeable

Battery

Base Station

Power supply

unit

World Adapters

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Vivatmo pro - Overview

Dashboard

Manage

measurement

orders

Enter Settings

Access data

management for

lists of:

- Patients

- Measurements

- Orders

Start a new

measurement

Connectivity status of handheld

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Vivatmo Pro – FeNO measurement

Petunjuk untuk user dan animasi untuk pasien

4.1

4.2

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Vivatmo Pro – FeNO measurement

Cara melakukan pengukuran

FURTHER IMPORTANT TIPPS

 Tidak menyebabkan iritasi dalam pengukuran

 Bila pasien gagal beberapa kali, lakukan break dan ganti animasinya

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Vivatmo Pro – Stability control

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Special Cases 1/2

Selalu gunakan mouthpiece baru

Vivatmo akan mendeteksi mouthpiece bekas dan akan minta yang baru

Jangan melepas mouthpiece

Reconditioning tidak akan selesai tanpa mouthpiece.
Reconditioning akan dilanjut secara otomatis ketika mouthpiece dipasang ulang

Vivatmo Pro – Stability control

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Special Cases 2/2

Battery running low

Lepaskan mouthpiece dan charge di base station.
Setelah 2-3jam, switch on handheld dan pasang

mouthpiece.

Reconditioning akan berlanjut automatis

Jangan diinterupsi saat reconditioning

Handheld tidak boleh dimatikan saat reconditioning.
Melepas battery akan menyebabkan alat tidak berfungsi.

Do not leave the device unattended during the process.

Vivatmo Pro – Stability control

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Vivatmo Pro – Petunjuk umum

Untuk start up, tekan tombol on/off 1 detik dan tunggu 5 detik untuk bereaksi
Switch on handheld secara terpisah dan tunggu koneksi
Untuk shut down tekan tombol on/off selama 3 detik

Settings-menu covers settings and seldom used functions
Status bar displays connectivity and device status
Drag up status bar to access the status screen:

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