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

Model Number PT101

Device Problem No Audible Alarm (1019)

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

Event Date 12/05/2022

Event Type  malfunction  

Manufacturer Narrative

(b)(4).Product background: the pt101 airvo 2 (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.Its 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 complaint airvo 2 was not evaulated by fisher and paykel healthcare (f&p).The complaint device is no longer in use.Our investigation is based on the information provided by the customer, previous investigations of similar complaints, and our knowledge of the product.Results:the customer has stated that the airvo 2 did not have an audible alarm.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.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.All above actions were implemented and achieved a 98% reduction in the number of complaints for units manufactured after 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.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 0.02% worldwide.

Event Description

A healthcare facility in california reported that a pt101 airvo 2 humidifier did not have an audible alarm.There was no reported patient involvement.

• Brand Name: AIRVO 2 HUMIDIFIER
• Type of Device: AIRVO 2 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: faranak gomarooni ; 17400 laguna canyon road; suite 300; irvine, CA 92618 ; 9494534000
• MDR Report Key: 16031195
• MDR Text Key: 306003656
• Report Number: 9611451-2022-01220
• Device Sequence Number: 1
• Product Code: BTT
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K131895
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Biomedical Engineer
• Type of Report: Initial
• Report Date: 12/05/2022

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: PT101
• Device Catalogue Number: PT101
• Device Lot Number: 2100212517
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 12/05/2022
• Initial Date FDA Received: 12/21/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 05/10/2017
• 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