MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD HEATED BREATHING TUBE; AIRVO HEATED BREATHING TUBE

Model Number 900PT561

Device Problems Improper or Incorrect Procedure or Method (2017); Obstruction of Flow (2423); Device Displays Incorrect Message (2591); Ambient Temperature Problem (2878); Output Problem (3005); Physical Resistance/Sticking (4012)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Type  malfunction  

Manufacturer Narrative

(b)(4).The complaint 900pt561 airvo heated breathing tube is expected but has not yet been received for evaluation.We will provide a follow up report upon completion of our investigation.

Event Description

A hospital in (b)(6) reported via a fisher & paykel healthcare (f&p) field representative that an airvo humidifier alarmed and when the hospital staff checked the 900pt561 airvo heated breathing tube, they noticed that the tube was covered by a pillow and the patient was lying on it.The tube was sticking to the pillow.There was no patient consequence.

Event Description

A hospital in australia reported via a fisher & paykel healthcare (f&p) field representative that an airvo humidifier alarmed and when the hospital staff checked the 900pt561 airvo heated breathing tube, they noticed that the tube was covered by a pillow and the patient was lying on it.The tube was sticking to the pillow.There was no patient consequence.

Manufacturer Narrative

(b)(4).Method: the complaint 900pt561 airvo heated breathing tube was returned to fisher & paykel healthcare (f&p) for investigation and was visually inspected and resistance tested.Result: a visual inspection of the subject 900pt561 tube revealed that the plastic in the middle part of the tube was melted.It was noted that the melted tubing was very clean with no sign of burning or smoke damage.The wires were insulated and no sign of arcing to the wires was observed.One of the heated breathing tube wires was broken in the middle, therefore the resistance of the tubing could not be measured.Conclusion: based on our observations of previous damaged heated breathing tubes, as well as the results of this investigation, the tube was very likely covered by material with a temperature greater than that of typical room conditions and/or was under compressive load for a considerable length of time.It is likely that heated breathing tube wire was broken in the middle when it was pulled from the pillow by the user.The heater wires are coated with teflon, which remains intact even under compressive load and has a much higher melting point than the breathing tube.During production the heater wires are 100% visually inspected using a camera system.The heater wires are also tested for resistance, continuity, polarity and pitch during production.Before the product leaves the line a full functional test is conducted under load.The airvo system is designed to comply with the electrical safety standard ul60601-1.The case is composed of a flame retardant material.The surface temperature of the heated breathing tube is within the limits specified by iso 8185 with regard to hot tube surface temperature not exceeding 44° celsius.There are many safety features incorporated into the airvo to prevent overheating and fire.These include: the heater wires in the heated breathing tube are coated with teflon, completely insulating them from the gas path.The pcb at the [patient] end of hose is over moulded with the thermoplastic polymer polypropylene, ensuring it is excluded from the gas path.The airvo contains a transient current detector, tcd.This tcd is tested on the production line.It is also checked by the control system when the airvo is powering up before each use.An 'over-temperature' sensor will automatically cut power to the motor, heater plate and heater wire if it detects any overheating.The airvo is constantly checking power in the heated breathing tube and turns the heater wire off if the measured power is too high.The user instructions that accompany the airvo 2 humidifier include the following warning: adding heat, above ambient levels, to any part of the breathing tube or interface, e.G.Covering with a blanket, or heating it in an incubator or overhead heater for a neonate, could result in serious injury.The user manual instructs the user to "use continuous oxygen monitoring on patients who would desaturate significantly in the event of disruption to their oxygen supply." the user manual also states that the "airvo 2 is for the treatment of spontaneously breathing patients who would benefit from receiving high-flow, warmed and humidified respiratory gases" and that "the unit is not intended for life support.".

• Brand Name: HEATED BREATHING TUBE
• Type of Device: AIRVO HEATED BREATHING TUBE
• Manufacturer (Section D): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• MDR Report Key: 8442461
• MDR Text Key: 139721637
• Report Number: 9611451-2019-00255
• Device Sequence Number: 0
• Product Code: BTT
• PMA/PMN Number: K162553
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup
• Report Date: 02/21/2019
• 2 Devices were Involved in the Event: 1 2

1 Patient was Involved in the Event

• Date FDA Received: 03/21/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 900PT561
• Device Catalogue Number: 900PT561
• Was Device Available for Evaluation?: Yes
• Date Manufacturer Received: 06/28/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1