MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD AIRVO 2 HUMIDIFIER; RESPIRATORY HUMIDIFIER

Model Number PT101

Device Problem No Audible Alarm (1019)

Patient Problems Burning Sensation (2146); Insufficient Information (4580)

Event Type  malfunction  

Event Description

A healthcare facility in finland reported via a fisher and paykel healthcare (f&p) field representative that a pt101 airvo 2 humidifier did not have an audible alarm.Fisher & paykel healthcare (f&p) has requested for additional information and related patient consequence.We will provide a follow up report upon completion of our investigation.

Manufacturer Narrative

(b)(4).Fisher & paykel healthcare (f&p) has requested for the complaint device to be returned for evaluation and has requested for additional information and related patient consequence.We will provide a follow up report upon completion of our investigation.Product background: the pt101 airvo 2 humidifier (airvo 2) device is an active humidifier with integrated flow generator that delivers high flow warmed and humidified respiratory gases to spontaneously breathing patients through a variety of patient interfaces.It's intended use is for the treatment of spontaneously breathing patients who would benefit from receiving high flow warmed and humidified respiratory gases.The airvo 2 device should not be used for life support purposes, and appropriate patient monitoring must be used at all times.

Event Description

A healthcare facility in finland reported via a fisher and paykel healthcare (f&p) field representative that a pt101 airvo 2 humidifier did not have an audible alarm for an empty water bag during patient use.The healthcare facility reported that the patient received air without humidity, causing mucosal damage.The patient received nasal spray in the nose as a local treatment and the healthcare facility stated that the patient was discharged.There were no further patient consequences.

Manufacturer Narrative

(b)(4), product background: the pt101 airvo 2 humidifier (airvo 2) device is an active humidifier with integrated flow generator that delivers high flow warmed and humidified respiratory gases to spontaneously breathing patients through a variety of patient interfaces.It's intended use is for the treatment of spontaneously breathing patients who would benefit from receiving high flow warmed and humidified respiratory gases.The airvo 2 device should not be used for life support purposes, and appropriate patient monitoring must be used at all times.Method: the subject device was received by fisher & paykel healthcare (f&p) where it was inspected by a trained f&p employee.The device was performance tested and the audible alarm function was checked.The device was then disposed of.Our investigation is based on the information provided by the customer, our evaluation of the subject device, previous investigations of similar complaints, and our knowledge of the product.Results: during testing it was found that the subject device did not have an audible alarm, confirming the reported event.Previous investigations into audio alarm failures have identified that the issue was due to a faulty speaker.Electrical resistance testing had shown the speaker's resistance to be out of specification or open circuit.The speaker is a supplied component that is assembled into the airvo 2.The airvo 2 speaker is intended to provide auditory alerts to the user and auditory alarms under certain conditions.The alarm system functionality must be checked prior to each patient use.The user instructions warn "if either alarm signal is absent, do not use the unit.Contact your fisher & paykel healthcare representative".In the case of speaker failures, a speaker will typically provide a distorted, intermittent or reduced sound level before becoming completely inaudible over time.This contributes to the early detection of this fault by users.It should also be noted that in the event of a speaker failure during use, the airvo 2 will continue to deliver therapy as per the set parameters.For any alarm condition, the device simultaneously displays a visual alarm alongside an auditory alarm and so in the absence of an audible alarm due to speaker failure, a visual alarm will still be displayed.The healthcare facility confirmed a visual alarm was displayed.The healthcare facility reported that the patient received air without humidity, causing mucosal damage.The patient received nasal spray in the nose as a local treatment and the healthcare facility stated that the patient was discharged.There were no further patient consequences.Conclusion: as part of ongoing product improvement initiatives, additional production quality controls at the supplier and at f&p were introduced.This included updated assembly processes, equipment and functional testing to verify speaker performance.A change was made to the instructions for use, to include instructions to verify the functionality of the speaker prior to each patient use.Additionally, a new speaker from a new supplier was also implemented in august 2017.It should be noted that this unit was manufactured prior to when the new speaker was implemented in august 2017.Further improvements were initiated in march 2019 which involved an update to the control pcb in order to reduce the mechanical stress on the speaker when operating.A historical search was conducted for the last 2 years which showed the speaker failure has not caused or contributed to any serious adverse events.The majority of reported speaker failures received currently, continue to be from units manufactured prior to the speaker change implemented in august 2017.The overall number of complaints also continues to decrease as the majority of units manufactured prior to the change are no longer in the field.The current failure rate per use for units manufactured after the change is less than (b)(4) worldwide.

• Brand Name: AIRVO 2 HUMIDIFIER
• Type of Device: RESPIRATORY HUMIDIFIER
• Manufacturer (Section D): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer (Section G): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer Contact: omid taheri ; 17400 laguna canyon road; suite 300; irvine, CA 92618 ; 8007923912
• MDR Report Key: 18629646
• MDR Text Key: 334671716
• Report Number: 9611451-2024-00068
• Device Sequence Number: 1
• Product Code: BTT
• UDI-Device Identifier: 09420012422286
• UDI-Public: (01)09420012422286(10)2100034878(11)160323
• Combination Product (y/n): N
• Reporter Country Code: FI
• PMA/PMN Number: K131895
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 01/03/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/02/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: PT101
• Device Catalogue Number: PT101
• Device Lot Number: 2100034878
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 02/27/2024
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 03/23/2016
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1
• Treatment: F&P 900PT561 HEATED BREATHING TUBE AND CHAMBER KIT; F&P OPT964 OPTIFLOW + ASYMMETRICAL NASAL CANNULA