MAUDE Adverse Event Report: RESPIRONICS, INC. DREAMSTATION AVAPS30; VENTILATOR, CONTINUOUS, NON-LIFE-SUPPORTING

Model Number	ESX1130S15
Medical Device Problem Code	Degraded (1153)
Health Effect - Clinical Codes	Headache (1880); Nausea (1970); Vomiting (2144)
Date of Event	09/17/2021
Type of Reportable Event	Malfunction
Event or Problem Description
The manufacturer was contacted in reference to the voluntary field safety notice / recall notification related to the sound abatement foam in certain cpap, bipap, and mechanical ventilator devices.The manufacturer received information alleging an issue related to a cpap device's sound abatement foam.The patient alleged of having vomiting, nausea and headaches.There was no report of serious or permanent patient harm or injury.The manufacture's investigation is ongoing.A follow up report will be submitted when the manufacture's investigation is complete.
Additional Manufacturer Narrative
As per additional information received on 05/22/2025: the device was returned to a third-party service center.During the evaluation of the device at the third-party service center, the device was visually inspected and foam particles were not observed inside the assembly.In addition, dust/dirt was found in contamination findings.Additionally, the patient¿s complaint was not confirmed, and the device was scrapped.**udi related data quality updates only** the udi in section d4 was previously reported in the incorrect format.The udi information has been updated to the correct format.In this report, box d, h has been updated/corrected.

• Brand Name: DREAMSTATION AVAPS30
• Common Device Name: VENTILATOR, CONTINUOUS, NON-LIFE-SUPPORTING
• Manufacturer (Section D): RESPIRONICS, INC.; 1001 murry ridge lane; murrysville PA 15668
• Manufacturer (Section G): RESPIRONICS, INC.; 1001 murry ridge lane; murrysville PA 15668
• Manufacturer Contact: melissa rosko ; 6501 living place; pittsburgh, PA 15208 ; 4125423300
• MDR Report Key: 17316250
• Report Number: 2518422-2023-15583
• Device Sequence Number: 14467674
• Product Code: MNS
• UDI-Device Identifier: 00606959426351
• UDI-Public: (01)00606959426351
• Combination Product (Y/N): N
• Initial Reporter Country: PO
• PMA/510(K) Number: K102465
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Distributor
• Initial Reporter Occupation: Other
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 07/11/2025

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: Lay User/Patient
• Device Model Number: ESX1130S15
• Device Catalogue Number: ESX1130S15
• Was Device Available for Evaluation?: No
• Date Returned to Manufacturer: 09/20/2022
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/01/2021
• Supplement Date Received by Manufacturer: 05/22/2025
• Initial Report FDA Received Date: 07/13/2023
• Supplement Report FDA Received Date: 07/11/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 12/18/2018
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-1974-2021
• Patient Sequence Number: 1
• Patient Sex: Unknown