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(b)(4) the customer returned one unit v5-10115 et tube, cf, 7.5 for investigation.The et tube was visually examined with and without magnification.Visual examination of the returned device revealed that the balloon cuff had multiple holes in it.A device history record review was performed and no relevant findings were identified.The ifu for this product states, "the tracheal tube cuff inflation system, including the valve, should be checked prior to intubation.If a malfunction is a detected in any part of the system, the tube should not be used." "care should be taken to avoid damaging the thin-walled cuffs during intubation.If cuff is damaged, the tube should not be used." the ifu also states, "the tracheal tube cuff should be slowly inflated with the minimum amount of air required to provide an effective tracheal seal.Do not inflate with a measured volume of air or by "feel" of pressure in the syringe since little resistance should be felt during inflation.Cuff volume and pressure should be monitored routinely to assure that an adequate tracheal seal is maintained and that the cuff has not become overinflated." the reported complaint was confirmed based upon the sample received.The returned et tube was found to have multiple holes in the balloon cuff which would prevent the cuff from staying inflated.A device history record review was performed with no evidence to suggest a manufacturing related cause.All et tubes are 100% inspected for inflation and deflation at the time of manufacturing.It is unlikely that this type of damage was present at the time of manufacturing.Therefore, based upon the damage observed, unintentional user error caused or contributed to this event.
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