MAUDE Adverse Event Report: TELEFLEX MEDICAL HUDSON ET TUBE, SHER-I-BRONCH, LS, 35 FR; TUBE, TRACHEAL/BRONCHIAL, DIFF

Model Number IPN048995

Device Problem Inflation Problem (1310)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 03/06/2023

Event Type  malfunction  

Event Description

Reported issue: the doctor found the cuff cannot be inflated before using it on the patient.Another device was used and there was no patient impact.

Manufacturer Narrative

Qn# (b)(4).The device history review for the et tube, sher-i-bronch, ls, 35 fr lot #73f2200323 investigation did not show issues related to the complaint.Teleflex will continue to monitor and trend related events.

Event Description

Reported issue: the doctor found the cuff cannot be inflated before using it on the patient.Another device was used and there was no patient impact.

Manufacturer Narrative

(b)(4).The customer returned one unit 5-16035 et tube, sher-i-bronch, ls, 35 fr for investigation.The et tube was returned out of its original packaging.Two suction catheters, both swivel connectors and the y connector were all returned in their original packaging.The returned et tube was visually examined with and without magnification.Visual examination of the returned et tube revealed that the sample appeared typical.No defects or anomalies were observed.A functional inspection was performed to attempt to inflate and deflate the balloon cuffs on the returned et tube.A lab inventory syringe filled with air was connected to the valve of the bronchial (blue) pilot balloon.Upon injection of air, both the bronchial balloon cuff and pilot balloon were able to properly inflate.Next, the syringe was refilled with air and connected to the valve of the tracheal (white) pilot balloon.Upon injection of air, the tracheal pilot balloon was able to properly inflate.However , the tracheal balloon cuff did not inflate at all.The inflation line appeared to be blocked.After successfully deflating the cuffs and pilot balloons, the et tube was submerged underwater to detect any leaks.Upon injection of air into both inflation lines, no leaks were detected.Next, water was injected into the tracheal inflation line to identify where the blockage in the inflation line was.Upon injection of the water, no water got past the distal end of the pilot balloon.Therefore , there appears to be an obstruction in the tracheal inflation line at the distal end of the pilot balloon.The obstruction was caused by adhesive material getting into the distal end of the pilot balloon during assembly and blocking the inflation line.A device history record review was performed and no relevant findings were identified.The ifu for this product states, "the cuff inflation system (cuffs, pilot balloons, valves) should be checked by inflation and deflation prior to use.If cuff is damaged, the tube should not be used.Care should be taken to avoid damaging the cuffs during intubation.If any one of the cuffs is damaged, the tube should not be used." "cuff pressure should be monitored routinely to assure that an adequate seal is maintained and that the cuffs have not become overinflated." "deflate all cuffs prior to repositioning the tube.Movement of the tube with cuffs inflated could result in patient injury or in damage to the cuffs, requiring a tube change.Verify the position of the tube after each repositioning." the reported complaint was confirmed based upon the sample received.Upon functional inspection, the tracheal (white) inflation line was found to be obstructed at the distal end of the pilot balloon which prevented the balloon cuff from inflating properly.The obstruction was caused by adhesive material getting into the distal end of the pilot balloon during assembly and blocking the inflation line.A non-conformance was previously opened to further investigate this complaint issue by the manufacturing site.Corrective actions were implemented in aug 2022 to help prevent this issue from recurring.The returned sample was manufactured prior to these corrective actions.

• Brand Name: HUDSON ET TUBE, SHER-I-BRONCH, LS, 35 FR
• Type of Device: TUBE, TRACHEAL/BRONCHIAL, DIFF
• Manufacturer (Section D): TELEFLEX MEDICAL; morrisville NC
• Manufacturer (Section G): TELEFLEX MEDICAL; rancho el descanso; tecate 21478 ; MX 21478
• Manufacturer Contact: katharine tarpley ; 3015 carrington mill blvd; morrisville, NC 27560 ; 9194332672
• MDR Report Key: 16674519
• MDR Text Key: 312631017
• Report Number: 3003898360-2023-00457
• Device Sequence Number: 1
• Product Code: CBI
• UDI-Device Identifier: 14026704617392
• UDI-Public: 14026704617392
• Combination Product (y/n): N
• Reporter Country Code: CH
• PMA/PMN Number: K180253
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Risk Manager
• Type of Report: Initial,Followup
• Report Date: 03/08/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/04/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: IPN048995
• Device Catalogue Number: 5-16035
• Device Lot Number: 73F2200323
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/20/2023
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 04/18/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 06/20/2022
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: A
• Patient Sequence Number: 1
• Treatment: NONE REPORTED; NONE REPORTED