BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BIPAP PLUS M-SERIES

    MDR report key: 1959111 · Received December 17, 2010

    Report

    Report Number
    2518422-2010-00138
    Event Type
    Malfunction
    Date Received
    December 17, 2010
    Date of Event
    November 1, 2010
    Report Date
    November 19, 2010
    Manufacturer
    RESPIRONICS, INC.
    Product Code
    BZD
    PMA / PMN Number
    K061034
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    METHOD (REVIEW OF COMPLAINT DATABASE). THE CAUSE(S) AND PATH OF THE FLUID INGRESS COULD NOT BE DETERMINED; HOWEVER, THE PRODUCT'S LABELING PROVIDES USER CARE AND HANDLING INSTRUCTIONS TO PREVENT WATER INGRESS FROM OCCURRING OR AFFECTING THE OPERATION OF THE DEVICE SHOULD IT INADVERTENTLY OCCUR (M SERIES USER MANUAL HEATED HUMIDIFIER, VERSION 01, PART NUMBER 1040469, PAGE 4, SECTION: WARNINGS AND CAUTIONS). THE MANUFACTURER CONCLUDES THE WATER INGRESS AND SUBSEQUENT PRODUCT FAILURE WERE CAUSED AND OR CONTRIBUTED TO BY A FAILURE OF THE PRODUCT USER TO APPLY THE MANUFACTURER'S CARE AND HANDLING INSTRUCTIONS WHEN USING THE DEVICE. EVALUATION OF THE RISK TO USERS RESULTING FROM ADULTERATION OF THE DEVICE'S AIR WAY INCLUDED AN ASSESSMENT OF THE DEVICE'S AIR PATH. THE DEVICE'S PATIENT AIR PATH, WHICH IS ISOLATED FROM THE ELECTRONICS COMPARTMENT, WAS FOUND TO BE NON-COMPROMISED AND IS CONCLUDED TO HAVE BEEN EFFECTIVE IN MITIGATING ANY RISK TO THE PRODUCT USER THAT MAY HAVE RESULTED FROM THE DEVICE'S PATIENT AIR PATH BEING COMPROMISED. EVALUATION OF THE RISK TO USERS ASSOCIATED WITH FIRE HAZARD INCLUDED AN ASSESSMENT OF THE EFFECTIVENESS IN THE DEVICE'S DESIGN IN MITIGATING THIS HAZARD. THE DEVICE'S HOUSING, MADE OF NON-FLAMMABLE MATERIALS CONFORMING TO (B)(4) STANDARDS, WAS CONCLUDED TO HAVE BEEN EFFECTIVE IN CONTAINING AND RESISTING ANY SUBSTANTIAL THERMAL INVOLVEMENT ASSOCIATED WITH THE DEVICE'S PCA FAILURE. THE BIPAP DEVICE IS CLEARED FOR AND INTENDED TO TREAT OBSTRUCTIVE SLEEP APNEA IN SPONTANEOUSLY BREATHING PATIENTS WEIGHING MORE THAN (B)(6). THE LOSS OF BIPAP THERAPY DOES NOT REPRESENT A SIGNIFICANT RISK OF HARM TO THE INTENDED USER POPULATION. COMPLAINT RECORDS FOR THE AFFECTED DEVICE WERE REVIEWED TO DETERMINE IF THE ISSUE IDENTIFIED IN THIS REPORT HAD PREVIOUSLY OCCURRED AND RESULTED IN AN ADVERSE EVENT. THE COMPLAINT RECORDS REVIEWED WERE RECORDED FROM (B)(6) 2006 (THE DATE THE AFFECTED DEVICE WAS RELEASED FOR DISTRIBUTION) TO (B)(6) 2010. THE REVIEW DETERMINED THAT NO REPORTS OR ALLEGATIONS OF ADVERSE EVENTS ASSOCIATED WITH THIS ISSUE HAD BEEN PREVIOUSLY REPORTED. THE CPAP DEVICE IN QUESTION WAS BEING USED IN CONJUNCTION WITH A PHILIPS RESPIRONICS EVERFLOW OXYGEN CONCENTRATOR AND AN M-SERIES HEATED HUMIDIFIER DEVICE. THE MANUFACTURER'S INVESTIGATION HAS CONCLUDED THAT THE FAILURE MODE IS ISOLATED TO THE CPAP DEVICE. ACCORDINGLY, THE CONCENTRATOR AND HUMIDIFIER ARE LISTED FOR CONCOMITANT DEVICES. BASED ON THE INVESTIGATION AND THESE FINDINGS, THE MANUFACTURER CONCLUDES THAT NO FURTHER ACTION IS APPROPRIATE.

    Description of Event or Problem · 1

    A DURABLE MEDICAL EQUIPMENT SUPPLIER (DME) REPORTED THAT A CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE (CPAP) HAD AWAKENED A PATIENT WITH A BURNING ODOR. THERMAL DAMAGE AND A VOID IN THE DEVICE ENCLOSURE WERE REPORTED. THERE WAS NO REPORT OF SMOKE, PROPERTY DAMAGE, INJURY OR HARM. THE DEVICE WAS EVALUATED BY THE MANUFACTURER. THE COMPLAINT OF THE DEVICE HAVING EMITTED A BURNING ODOR WAS CONFIRMED. THERMAL DAMAGE TO THE TOP ENCLOSURE OF THE DEVICE WAS OBSERVED IN THE FORM OF DEFORMATION AND A THERMAL VOID. THE DAMAGE TO THE ENCLOSURE IS PROXIMAL TO A THERMALLY DAMAGED PORTION OF THE DEVICE'S PRINTED CIRCUIT ASSEMBLY (PCA) WHICH CONTAINS THE MOTOR DRIVING CIRCUITRY. EVIDENCE OF FLUID INGRESS WAS OBSERVED ON THE PCA AND OTHER AREAS INSIDE THE DEVICE'S HOUSING. THE MANUFACTURER COMPLETED THEIR INVESTIGATION OF THE REPORTED COMPLAINT AND HAS CONCLUDED THE FAILURE MODE IS CAUSED BY THE PRESENCE OF CONDUCTIVE FLUID AT THE LOCATION OF THE MOTOR DRIVING FIELD EFFECT TRANSISTORS (FET) ON THE DEVICE'S THERAPY PCA. CONDUCTIVE FLUID IN THIS LOCATION CAN, IN SOME CASES, ALLOW ELECTRICAL CURRENT FLOW BETWEEN THE PINS AND COMPONENTS OF THE MOTOR DRIVING CIRCUIT, CAUSING THE CONTROLLING TRANSISTOR TO CONTINUOUSLY POWER ONE OR MORE OF THE MOTOR-DRIVING FETS. CONTINUOUS POWER TO THE MOTOR-DRIVING FETS CAN CAUSE AN INCREASE IN COMPONENT HEAT WHICH CANNOT BE DISSIPATED EFFECTIVELY THROUGH THE COMPONENT'S HEAT SINK. THE INCREASED HEAT CAN CAUSE DEFORMATION AND, POTENTIALLY, VOIDS IN THE DEVICE ENCLOSURE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 BIPAP PLUS M-SERIES VENTILATOR, NON-CONTINUOUS (RESPIRATOR) BZD RESPIRONICS, INC. 600M

    Patients

    Seq Age Sex Outcome Treatment
    1 M-SERIES (DC) HEATED HUMIDIFIER, (B)(4)| EVERFLO CONCENTRATOR, (B)(4)| (B)(4)