MAUDE Adverse Event Report: SUN MED AIRLIFE; AIRLIFE VERSO AIRWAY ACCESS ADAPTER

Model Number	CSC100
Medical Device Problem Code	Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/13/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The product involved in the report has not been returned for evaluation.A review of the device history record is in-progress.All information reasonably known as of 15 oct 2025 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Event or Problem Description
It was reported: the anxious intubated patient, in the intensive care unit (icu), pulled the closed suction catheter (csc) off from the verso adapter.Additionally, the duck valve, inside the verso adapter csc100, fell down into the swivel part of the device, where the staff discovered it.The system was changed; there was no direct impact on the patient's condition.
Additional Manufacturer Narrative
Additional information-investigation completion: d4; h2; h6 the actual complaint product was not returned for evaluation; however, the reporter provided photographic/videographic evidence; analysis of the photographic evidence confirmed the complaint as reported; however, the root cause was not determined.The device history record for lot 24024254 was reviewed and the product was produced according to product specifications.All information reasonably known as of 28 nov 2025 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Event or Problem Description
It was reported: the anxious intubated patient, in the intensive care unit (icu), pulled the closed suction catheter (csc) off from the verso adapter.Additionally, the duck valve, inside the verso adapter csc100, fell down into the swivel part of the device, where the staff discovered it.The system was changed; there was no direct impact on the patient's condition.

• Brand Name: AIRLIFE
• Common Device Name: AIRLIFE VERSO AIRWAY ACCESS ADAPTER
• Manufacturer (Section D): SUN MED; 2710 north ridge dr nw; ste a; grand rapids MI
• Manufacturer (Section G): SUN MED; productos urologos de mexico s; no. 85 parque indus. mexicali; mexicali baja california, mx ; MX
• Manufacturer Contact: racheal cooper ; 2710 north ridge dr nw; ste a; grand rapids, MI
• MDR Report Key: 23305971
• Report Number: 1314417-2025-00085
• Device Sequence Number: 5827568
• Product Code: CAI
• UDI-Device Identifier: 10889483598764
• UDI-Public: (01)10889483598764(10)24024254(11)241101(17)291129
• Combination Product (Y/N): N
• Initial Reporter Country: SW
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/28/2025

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: Health Professional
• Device Model Number: CSC100
• Device Catalogue Number: CSC100
• Device Lot Number: 24024254
• 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: 09/16/2025
• Supplement Date Received by Manufacturer: 10/29/2025
• Initial Report FDA Received Date: 10/15/2025
• Supplement Report FDA Received Date: 11/28/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 11/01/2025
• 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