It was reported that a bivona® adult tts¿ tracheostomy tube had the cuff leaking after tube was in place for days.The event occurred while the patient was sitting in their power wheelchair doing no activity.The cuff was inflated with water, ranging 7.5-10ml.It was noted that if a leak developed, the tracheostomy was adjusted and more water was added to the cuff.The husband of the patient heard audible sounds from the patient "as if air was leaking from around the cuff," and he stated that audible coughing was only heard when cuff ruptured and water leaked out.The husband observed multiple leaks upon taking out the tracheostomy tube; he stated there were no pinholes on the cuff, water leaked from the top of the cuff, and the "seam" where the cuff meets the shaft detached as if there was not enough adhesive to seal and hold the cuff down.When the husband injected water into the pilot balloon, water shot out of the cuff and up through the tracheostomy tube.The husband noted he does not check cuff patency prior to insertion.Tracheostomy tube was placed by husband by taking the tube out of the sterile container, lubricating the tube and cuff with ky jelly, and intubating the tube.These steps were done since (b)(6) 2016.An emergent tracheostomy change was required as the cuff would not hold water.No patient injury was reported.
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A used 7.0mm tts¿ tracheostomy tube was returned for investigation; the device was returned with two additional tracheostomy tubes.During functional testing, a syringe was used to insert 14cc of air into the device cuff; a small leak was detected on the cuff.Using magnification the cut was examined and a tiny abraded area was observed.No evidence was found of the cuff detaching from the shaft.Investigation was unable to determine the root cause of the cut on the cuff; however, no evidence was found to indicate a manufacturing defect.(b)(4).
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