The manufacturer received information alleging a ventilator failed to alarm for a patient disconnect.The patient was taken to a hospital.No permanent injury was reported.The ventilator was being used with a 15 millimeter circuit and a heated humidifier.Following the event, the patient's physician activated the low minute ventilation alarm.The ventilator is currently in use with the patient.Any accessory that could cause increased resistance within the patient circuit can result in the patient circuit disconnect alarm not functioning in the event of a patient circuit disconnect.Other alarms, such as low tidal volume, low minute volume, low respiratory rate and apnea should be set appropriately.These alarms appear to have been disabled at the time of the event.Following the event, the patient's physician activated the low minute ventilation alarm.Device labeling states the following: "prior to placing a patient on the ventilator, a clinical assessment should be performed to determine: ··the device alarm settings ··needed alternative ventilation equipment ··if an alternative monitor (i.E.An alarming pulse oximeter or respiratory monitor) should be used for ventilator dependent patients, do not rely on any single alarm to detect a circuit disconnect condition.The low tidal volume, low minute ventilation, low respiratory rate, and apnea alarms should be used in conjunction with the circuit disconnect and low peak inspiratory pressure alarms.Test the operation of the circuit disconnect function daily and whenever a change is made to the patient circuit.An increase in circuit resistance can prevent proper operation of some alarms.Speaking valves, heat moisture exchangers (hmes), and filters create additional circuit resistance and may affect the performance of alarms chosen for circuit disconnect protection".
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