MAUDE Adverse Event Report: VYAIRE MEDICAL AIRLIFE¿ AUTOFILL HUMIDIFICATION CHAMBER; INSPIRATORY LINE HUMIDIFICATION CHAMBER, SINGLE-USE

Model Number	AIRLIFE¿ AUTOFILL HUMIDIFICATION CHAMBER
Medical Device Problem Code	Contamination /Decontamination Problem (2895)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/15/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device evaluated by mfr: at this time, the suspect device has not been returned for evaluation.No root cause has been determined yet.Vyaire medical will submit a supplemental report in accordance with 21 cfr section 803.56 if additional information becomes available.
Event or Problem Description
The customer reported that the airlife¿ autofill humidification chamber experienced deposits in the chamber during use.The customer confirmed that there was no patient harm associated with the reported event.
Additional Manufacturer Narrative
Result of investigation: the suspect device was not returned for evaluation.The reported lot number and retained samples were tested and no trace of contamination were detected.No samples were returned and was unable to further investigate the complaint.Vyaire medical will submit a supplemental report in accordance with 21 cfr section 803.56 if additional information becomes available.

• Brand Name: AIRLIFE¿ AUTOFILL HUMIDIFICATION CHAMBER
• Common Device Name: INSPIRATORY LINE HUMIDIFICATION CHAMBER, SINGLE-USE
• Manufacturer (Section D): VYAIRE MEDICAL; 510 technology dr; irvine IL 92618
• Manufacturer (Section G): CHINAMED PRODUCTS (CHINA) LTD.; xin tang industrial park; jiao tang town gaoyao district; 44526 100; CH 44526100
• Manufacturer Contact: erika bonilla ; 510 technology dr; irvine, IL 92618 ; 7149227837
• MDR Report Key: 12661843
• Report Number: 3003799815-2021-00002
• Device Sequence Number: 4480154
• Product Code: BZD
• UDI-Device Identifier: 10190752144446
• UDI-Public: (01)10190752144446(10)CM20P27
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• PMA/510(K) Number: K031745
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/15/2021

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
• Operator of Device: Health Professional
• Device Model Number: AIRLIFE¿ AUTOFILL HUMIDIFICATION CHAMBER
• Device Catalogue Number: AH290
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/15/2021
• Supplement Date Received by Manufacturer: 12/21/2022
• Initial Report FDA Received Date: 10/19/2021
• Supplement Report FDA Received Date: 01/04/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown