MAUDE Adverse Event Report: SALTER LABS N/A; ADULT. ETCO2/O2 NASAL DIVIDED CANNULA, MALE LUER STYLE CO2 CONNECTOR. CLOSE

Model Number	49SOFT-14-14
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Low Oxygen Saturation (2477)
Date of Event	10/01/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The product involved in the report has not been returned.A review of the device history record is in-progress.All information reasonably known as of 31 oct 2025 has been included in the health authority report.Should additional information be obtained a follow-up health authority report will be provided.The information provided by airlife.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 airlife.Airlife 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 airlife complaint database and is 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 a airlife product is defective or causes serious injury.
Event or Problem Description
It was reported that they come apart at multiple sites.
Event or Problem Description
It was reported that they come apart at multiple sites.
Additional Manufacturer Narrative
The product involved in the report has not been returned.A review of the device history record is in-progress.All information reasonably known as of 31 oct 2025 has been included in the health authority report.Should additional information be obtained a follow-up health authority report will be provided.The information provided by airlife.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 airlife.Airlife 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 airlife complaint database and is identified as complaint - (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 a airlife product is defective or causes serious injury.Dhr review: based on the device history record (dhr) review there were no abnormal processing issues noted.All products/packaging were produced per the approved manufacturing procedures, specifications, and inspections.Risk assessment: the ultimate risk is low, as that is the highest risk of the patient/caregiver and regulatory/compliance considerations: 1.Patient/caregiver: performed risk assessment with rma (b)(4) revision 5; the most closely associated risk is id r112 (p1=1, p2=1) with a probability of harm occurring p=1 and severity s=2 which is low risk.The calculated p1 based on complaints and sales in the previous 24 months is 1/5 - improbable.Therefore, the probability of harm occurring (p) remains the same as the rma and is determined to be low risk per ref-20001-c1 rev2.2.Regulatory/ compliance: reviewed ref-20001-c1 rev2, and there is low regulatory/ compliance risk.3.Brand recognition and customer impact: reviewed ref-20001-c1 rev2, and there is medium brand recognition/customer impact.Complaint history review: the complaint history was reviewed in grand avenue from reported dates 01-oct-2023 through 01-oct-2025, for the etco2 part family and failure mode "tubing is not connected or easily disconnected".There were 8 other complaint(s) reported for the same issue and part number under complaint-(b)(4) during the same timeframe.Sales = (b)(4) ea.Calculated occurrence (p1) = (9 complaint(s) / (b)(4)).Occurrence ranking = 1/5 - improbable.

• Brand Name: N/A
• Common Device Name: ADULT. ETCO2/O2 NASAL DIVIDED CANNULA, MALE LUER STYLE CO2 CONNECTOR. CLOSE
• Manufacturer (Section D): SALTER LABS; 30 spur drive; el paso TX 79906
• Manufacturer (Section G): SALTER LABS DE MEXICO DE S.A. DE C.V.; blvd. independencia #2167 parq; ind. las ameri - hor sur cd ju; chihuahua mexico, mexico 32596 ; MX 32596
• Manufacturer Contact: melissa brickley ; 2710 northridge dr nw suite a; grand rapids, MI 49544 ; 6162598415
• MDR Report Key: 23444237
• Report Number: 3004748541-2025-00106
• Device Sequence Number: 4632926
• Product Code: CCK
• UDI-Device Identifier: 00607411945816
• UDI-Public: (01)00607411945816(10)571042
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: K151421
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Distributor
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 03/04/2026

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: 49SOFT-14-14
• Device Catalogue Number: 49SOFT-14-14
• Device Lot Number: 571042
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/01/2025
• Supplement Date Received by Manufacturer: 10/01/2025
• Initial Report FDA Received Date: 10/31/2025
• Supplement Report FDA Received Date: 03/04/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown