It was reported that the patient was using a bivona® 8.0mm aire-cuf tracheostomy tube and the pilot balloon was over inflating on one side and causing some trouble a with ventilation on a home bound trached patient.The fault was discovered while testing the cuff patency prior to use with air by the spouse/caregiver/nurse as well as respiratory therapist.Significant ventilation issues were noticed 7-10 days prior to death, the patient was ultimately unresponsive to tracheostomy changes and deep suctioning.It was also reported that these events happened on 3 tracheostomy tubes and the last "live" download was on (b)(6) 2017, indicating high pip (peak inspiratory pressure) alarm started to frequently develop about 10 days prior to death.The patient was switched back to a different manufacture tracheostomy tube on (b)(6) 2017, before the time of sudden death.It was reported that the assumed death was due to cardiac arrest not an airway issue.
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The customer returned thirteen devices for investigation.Eleven of the devices corresponded to a non-reportable complaint and two devices were associated with two reportable complaints.It could not be determined which device was associated with which occurrence; therefore, the investigation of the thirteen devices will be used for the medwatch.The following mfr were submitted related to the evaluation: 3012307300-2017, 00514 and 3012307300-2017-00628.Thirteen portex® bivona® mid-range aire-cuf® adult tracheostomy tubes of varying sizes were returned for investigation.The thirteen devices were randomly assigned a number for investigation.Visual inspection of the devices was performed using the unaided eye and under normal plant lighting.No obvious defects or anomalies were detected with twelve of the devices.One device, identified as number six, displayed wear marks on the cuff.During functional testing all thirteen devices were inflated with 10ml of air.The cuff symmetry was then measured for each device by measuring from the center point of the shaft to the smaller side of the outer diameter of the cuff and then by measuring from the center point of the shaft to the larger outer diameter of the cuff.All returned devices were determined to meet manufacturing specification allowance for aire-cuf® devices.Investigation was unable to confirm the reported issue and all devices were found to operate as intended.
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