MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD OPTIFLOW + ADULT NASAL CANNULA; BTT

Model Number OPT944

Device Problems Break (1069); Detachment of Device or Device Component (2907)

Patient Problem Low Oxygen Saturation (2477)

Event Type  malfunction  

Event Description

A healthcare facility in (b)(6) reported, via a fisher & paykel healthcare (f&p) field representative, that the tubing of an opt944 optiflow + adult nasal cannula was damaged whilst the patient was placed back on the bed.It was further reported that the patient desaturated.No further patient consequences were reported.

Manufacturer Narrative

(b)(4).Fisher & paykel healthcare (f&p) is currently in the process of retrieving further information and the subject opt944 optiflow + adult nasal cannula for evaluation.We will provide a follow up report upon completion of our investigation.

Manufacturer Narrative

(b)(4).The opt944 optiflow + adult nasal cannula is the nasal cannula patient interface for delivery of humidified respiratory gases, including those who are receiving nasal high flow therapy.Nhf therapy is intended for use with spontaneously breathing patients and use of the airvo 2 humidifier unit is not intended for life support.It consists of a lightweight delivery tube connected to a rigid plastic base and soft nasal prongs (nasal interface).This allows the device to be light weight and durable.The interface is held in place by a head strap and features a head strap clip which works in tandem with the tubing clip (attaches to the patient's clothing/bedding) to support the weight of the circuit and prevent the cannula being dislodged.Optiflow + interfaces are designed for use with the airvo 2 series of humidification devices.Method: the healthcare facility provided some additional information upon request, and the opt944 optiflow + adult nasal cannula was returned to f&p new zealand for evaluation.An investigation was carried out by f&p new zealand which was based on the information provided by the healthcare facility, the evaluation of the subject opt944 optiflow + adult nasal cannula and f&p's knowledge of the product.Results: visual inspection of the returned cannula revealed that the tubing was detached from the 3-way connector end.Conclusion: our investigation was unable to determine the cause of the observed damage to the returned opt944 optiflow + adult nasal cannula.Based on our knowledge of the product, the reported damage is likely to have been caused by the tubing being subjected to excessive force during use.Manufacturing controls include inspections during production for visual defects including cracks, tears, inclusions, discoloration and stretching or deformation.Any product that fails the visual inspection is disposed of.The subject opt944 optiflow + adult nasal cannula would have met the required specifications.The user instructions which accompany the opt944 optiflow + adult nasal cannula show in pictorial format the correct placement and fitting of the cannula, including ensuring the headstrap clip and the tubing clip are appropriately attached.The user instructions also warn: "ensure head strap clip is attached, to prevent cannula from being pulled out of the nares." "cannula can become unattached if not used with the head strap clip." "attach tubing clip to clothing/bedding to prevent cannula from pulling off face." "appropriate patient monitoring must be used at all times.Failure to monitor the patient may result in loss of therapy, serious injury or death." "do not crush or stretch tube, to prevent loss of therapy." "failure to use the set-up described above can compromise performance and affect patient safety.

Event Description

A healthcare facility in france reported, via a fisher & paykel healthcare (f&p) field representative, that the tubing of an opt944 optiflow + adult nasal cannula was damaged whilst the patient was placed back on the bed.It was further reported that the patient desaturated for two minutes, the cannula was then replaced and no further patient consequences were reported.

• Brand Name: OPTIFLOW + ADULT NASAL CANNULA
• Type of Device: BTT
• 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: faranak gomarooni ; 17400 laguna canyon road,; suite 300; irvine, CA 92618 ; 9494534000
• MDR Report Key: 13665085
• MDR Text Key: 289260084
• Report Number: 9611451-2022-00212
• Device Sequence Number: 1
• Product Code: BTT
• UDI-Device Identifier: 09420012429117
• UDI-Public: (01)09420012429117(10)2101637574(11)210517
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K162553
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Pharmacist
• Type of Report: Initial,Followup
• Report Date: 02/22/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: OPT944
• Device Catalogue Number: OPT944
• Device Lot Number: 2101637574
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 02/22/2022
• Initial Date FDA Received: 03/04/2022
• Supplement Dates Manufacturer Received: 04/11/2022
• Supplement Dates FDA Received: 05/07/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/17/2021
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: F&P PT101 AIRVO 2 HUMIDIFIER.
• Patient Age: 79 YR