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Qn# (b)(4).The customer returned one unit 5-22215 et tube, preformed cuffed oral, 7.5 for investigation.The et tube was visually examined with and without magnification.Visual examination of the returned device revealed that there was a large hole in the balloon cuff.The hole was indicative of the cuff being overinflated.Over-inflation would cause the balloon cuff to burst.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 detected in any part of the inflation 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, "deflate cuff prior to repositioning the tube.Movement of the tube with the cuff inflated could result in patient injury or in damage to the cuff, requiring a tube change.Verify the position of the tube after each repositioning." the reported complaint was confirmed based upon the sample received.The returned et tube was found to have a large hole in the balloon cuff.The hole was indicative of the cuff being over-inflated which would cause the balloon cuff to burst.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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