MAUDE Adverse Event Report: VYAIRE MEDICAL WATER STERILE F/INHALATION 2000ML 6/CS; STERILE SOLUTION STORAGE BOTTLE, SINGLE-USE

Model Number	WATER STERILE F/INHALATION 2000ML 6/CS
Medical Device Problem Code	Contamination /Decontamination Problem (2895)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/06/2022
Type of Reportable Event	Malfunction
Event or Problem Description
The customer reported to vyaire medical that there was a rust-colored or dark-red substance attached to the to the humidification chamber's inner plastic and floating inside the water of the humidification chamber while on a patient.No harm is associated with the event.
Additional Manufacturer Narrative
At this time, the suspect device has not been returned for evaluation.Therefore, root cause has not been determined yet.Vyaire medical will submit a supplemental report in accordance with 21 cfr section 803.56 if additional information becomes available.".
Additional Manufacturer Narrative
Device evaluation: g3, g6, h2, h3, h6 and h10.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: WATER STERILE F/INHALATION 2000ML 6/CS
• Common Device Name: STERILE SOLUTION STORAGE BOTTLE, SINGLE-USE
• Manufacturer (Section D): VYAIRE MEDICAL; 510 technology dr; irvine IL 92618
• Manufacturer (Section G): LABORATORIOS PISA; sa de cv carretera san isidro; 7000 tlajomulco de zuniga; jalisco, 45645 ; MX 45645
• Manufacturer Contact: erika bonilla ; 510 technology dr; irvine, IL 92618 ; 7149227837
• MDR Report Key: 15154085
• Report Number: 3013421741-2022-00018
• Device Sequence Number: 20182166
• Product Code: BTT
• UDI-Device Identifier: 10885403026607
• UDI-Public: (01)10885403026607(10)Q2201058
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• PMA/510(K) Number: K090915
• 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): 07/06/2022

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
• Operator of Device: Health Professional
• Device Model Number: WATER STERILE F/INHALATION 2000ML 6/CS
• Device Catalogue Number: 2D0737
• Device Lot Number: Q2201058
• 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: 07/06/2022
• Supplement Date Received by Manufacturer: 04/02/2023
• Initial Report FDA Received Date: 08/02/2022
• Supplement Report FDA Received Date: 02/15/2023
• 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: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown