FISHER & PAYKEL HEALTHCARE
Report
- Report Number
- 9611451-2025-02140
- Event Type
- Malfunction
- Date Received
- December 22, 2025
- Report Date
- January 9, 2025
- Manufacturer
- FISHER & PAYKEL HEALTHCARE LTD
- Product Code
- BTT
- UDI-DI
- 09420012422286
- Removal / Correction Number
- 9611451-09/10/2025-001-C
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- SP
- Reporter Occupation
- OTHER
- Health Professional
- N
Narratives
(B)(4). D4, G4: PT101EW IS NOT SOLD IN THE USA, BUT IT IS SIMILAR TO A PRODUCT WHICH IS SOLD IN THE USA (PT101US). THE 510(K) FOR THE SIMILAR PRODUCT IS K131895. FISHER & PAYKEL HEALTHCARE (F&P) IS CURRENTLY IN THE PROCESS OF COMPLETING F&P'S INVESTIGATION. F&P WILL PROVIDE A FOLLOW UP REPORT UPON COMPLETION OF F&P'S INVESTIGATION. PRODUCT BACKGROUND: THE PT101 AIRVO 2 HUMIDIFIER (AIRVO 2) IS AN ACTIVE HUMIDIFIER WITH INTEGRATED FLOW GENERATOR THAT DELIVERS HIGH FLOW WARMED AND HUMIDIFIED RESPIRATORY GASES TO SPONTANEOUSLY BREATHING PATIENTS THROUGH A VARIETY OF PATIENT INTERFACES. ITS INTENDED USE IS FOR THE TREATMENT OF SPONTANEOUSLY BREATHING PATIENTS WHO WOULD BENEFIT FROM RECEIVING HIGH FLOW WARMED AND HUMIDIFIED RESPIRATORY GASES. THE AIRVO 2 DEVICE SHOULD NOT BE USED FOR LIFE SUPPORT PURPOSES, AND APPROPRIATE PATIENT MONITORING MUST BE USED AT ALL TIMES.
(B)(4). D4,G4: PT101EW IS NOT SOLD IN THE USA, BUT IT IS SIMILAR TO A PRODUCT WHICH IS SOLD IN THE USA (PT101US). THE 510(K) FOR THE SIMILAR PRODUCT IS K131895. PRODUCT BACKGROUND: THE PT101 AIRVO 2 HUMIDIFIER (AIRVO 2) IS AN ACTIVE HUMIDIFIER WITH INTEGRATED FLOW GENERATOR THAT DELIVERS HIGH FLOW WARMED AND HUMIDIFIED RESPIRATORY GASES TO SPONTANEOUSLY BREATHING PATIENTS THROUGH A VARIETY OF PATIENT INTERFACES. IT'S INTENDED USE IS FOR THE TREATMENT OF SPONTANEOUSLY BREATHING PATIENTS WHO WOULD BENEFIT FROM RECEIVING HIGH FLOW WARMED AND HUMIDIFIED RESPIRATORY GASES. THE AIRVO 2 DEVICE SHOULD NOT BE USED FOR LIFE SUPPORT PURPOSES, AND APPROPRIATE PATIENT MONITORING MUST BE USED AT ALL TIMES. METHOD: THE SUBJECT AIRVO 2 WAS RECEIVED AT THE FISHER & PAYKEL HEALTHCARE (F&P) REGIONAL OFFICE IN FRANCE WHERE IT WAS INSPECTED BY A TRAINED F&P SERVICE TECHNICIAN AND THE POWER OUT ALARM FUNCTIONALITY WAS CHECKED. F&P'S INVESTIGATION IS BASED ON THE INFORMATION OBTAINED FROM THE HEALTHCARE FACILITY, THE INFORMATION PROVIDED BY THE F&P SERVICE TECHNICIAN, PREVIOUS INVESTIGATIONS OF SIMILAR COMPLAINTS, AND F&P'S KNOWLEDGE OF THE PRODUCT. RESULTS: DURING TESTING IT WAS FOUND THAT THE POWER OUT ALARM OF THE AIRVO 2 SOUNDED FOR LESS THAN 120 SECONDS. THERE WAS NO PATIENT INVOLVEMENT AS THE ISSUE WAS FOUND WHILST THE DEVICE WAS NOT IN USE ON A PATIENT. CONCLUSION: BASED ON F&P'S INVESTIGATION, EVALUATION OF THE SUBJECT AIRVO 2, KNOWLEDGE OF THE PRODUCT, AND PREVIOUS INVESTIGATIONS OF SIMILAR COMPLAINTS, THE POWER OUT ALARM OF THE AIRVO 2 SOUNDING FOR LESS THAN 120 SECONDS IS DUE TO THE AGING OF COMPONENT SUPERCAPACITORS DUE TO UNANTICIPATED USAGE PATTERNS IN THE FIELD. A REVIEW OF ALL-TIME COMPLAINT DATA HAS CONFIRMED THAT GLOBALLY THERE HAVE BEEN NO EVENTS WITH SERIOUS INJURY OR DEATH RELATED TO THE POWER OUT ALARM SOUNDING FOR LESS THAN 120 SECONDS. F&P'S INVESTIGATION FOUND IT LIKELY THAT DURING THE COVID-19 PANDEMIC, AIRVO 2 DEVICES WERE KEPT CONTINUOUSLY CONNECTED TO MAINS POWER TO ENSURE IMMEDIATE AVAILABILITY, GIVEN THE URGENCY AND UNPREDICTABILITY OF RESPIRATORY DETERIORATION IN COVID-19 PATIENTS. THIS PRACTICE ALIGNS WITH HOSPITAL PROTOCOLS, WHICH EMPHASIZE READINESS AND RAPID DEPLOYMENT OF RESPIRATORY SUPPORT EQUIPMENT IN HIGH-ACUITY SETTINGS. THE ORIGINAL LIFE TESTING CARRIED OUT ON AIRVO 2 DEVICES ASSUMED THAT THE DEVICES WERE DISCONNECTED FROM MAINS BETWEEN THERAPY SESSIONS AND AS PRACTICES HAVE EVOLVED, THIS NO LONGER REFLECTS REAL WORLD USAGE PATTERNS, PARTICULARLY DURING PANDEMIC CONDITIONS WHEN DEVICE AVAILABILITY WAS CRITICAL AND SINCE CLINICAL PRACTICES HAVE SHIFTED. F&P'S INVESTIGATION ALSO ASSESSED THE MANUFACTURING CONTROLS AND DETERMINED THEY WERE SUFFICIENT AND ADEQUATE. IN ADDITION, AS THE ROOT CAUSE POINTED TO USAGE IN FIELD, NO FURTHER CHANGES TO THE MANUFACTURING OR SUPPLIER PROCESSES WAS DEEMED NECESSARY. DURING THE MANUFACTURING PROCESS, QUALITY CONTROL MEASURES ENSURE EACH MANUFACTURED AIRVO 2 MEETS SPECIFICATION. THESE QUALITY CONTROL MEASURES ARE PERFORMED AT THE END OF THE FINAL ASSEMBLY PROCESS ON 100% OF THE MANUFACTURED UNITS. ANY UNIT THAT FAILS ANY OF THESE TESTS IS REJECTED. F&P HAVE UPDATED TEST PROTOCOLS TO SPECIFY THAT TEST DEVICES BE POWERED 24 HOURS A DAY I.E. WORST-CASE, AND F&P EXPECT THIS CHANGE TO COVER ANY FURTHER UNEXPECTED OPERATIONAL DEVIATIONS OR UNANTICIPATED CHANGES IN USAGE PATTERNS. THIS UPDATE TO F&P'S TEST PROTOCOLS WILL BE USED IN ANY NEW DEVELOPMENT OR CHANGE TO THE DEVICE. FURTHERMORE, AN UPDATE TO THE DISINFECTION KIT USER MANUAL OF THE AIRVO 2 WAS MADE TO INCLUDE A REGULAR TEST OF THE POWER OUT ALARM, TO BE CARRIED OUT IN BETWEEN EACH PATIENT USE. THIS CHANGE WAS COMMUNICATED TO USERS THROUGH A VOLUNTARY FIELD SAFETY NOTICE IN SEPTEMBER 2025. IN RESPONSE TO THIS CHANGE, CUSTOMERS ARE CONDUCTING THE REGULAR TEST IN BETWEEN PATIENT USE AND REPORTING ANY FAILURES. THE USER INSTRUCTION (UI) OF THE AIRVO 2 HUMIDIFIER STATES: "IF EITHER ALARM SIGNAL IS ABSENT, DO NOT USE THE UNIT. CONTACT YOUR FISHER & PAYKEL HEALTHCARE REPRESENTATIVE." "THE UNIT IS NOT INTENDED FOR LIFE SUPPORT." "APPROPRIATE PATIENT MONITORING MUST BE USED AT ALL TIMES. LOSS OF POWER MEANS LOSS OF THERAPY." "USE CONTINUOUS OXYGEN MONITORING ON PATIENTS WHO WOULD DESATURATE SIGNIFICANTLY IN THE EVENT OF DISRUPTION TO THEIR OXYGEN SUPPLY."
ON 13 NOVEMBER 2025, A HEALTHCARE FACILITY REPORTED VIA A FISHER & PAYKEL (F&P) FIELD REPRESENTATIVE THAT A PT101 AIRVO 2 HUMIDIFIER (AIRVO 2) SWITCHED OFF DURING USE. THE HEALTHCARE FACILITY DID NOT CONFIRM WHETHER THE SUBJECT DEVICE WAS UNPLUGGED OR IF MAINS POWER WAS LOST. ON 3 DECEMBER 2025, THE SUBJECT AIRVO 2 WAS RECEIVED AT THE FISHER & PAYKEL HEALTHCARE (F&P) REGIONAL OFFICE IN FRANCE WHERE IT WAS INSPECTED BY A TRAINED F&P SERVICE TECHNICIAN AND THE POWER OUT ALARM FUNCTIONALITY WAS CHECKED. DURING DEVICE EVALUATION AT THE F&P REGIONAL OFFICE IN FRANCE, IT WAS FOUND THAT THE POWER OUT ALARM OF THE SUBJECT DEVICE SOUNDED FOR LESS THAN 120 SECONDS. THIS WAS REPORTED SUBSEQUENT TO A FIELD SAFETY NOTICE INFORMING USERS OF A CHANGE TO THE DISINFECTION KIT USER MANUAL OF THE AIRVO 2 TO INCLUDE A REGULAR TEST OF THE POWER OUT ALARM, TO BE CARRIED OUT IN BETWEEN EACH PATIENT USE. THERE WAS NO REPORTED PATIENT INVOLVEMENT.
ON 13 NOVEMBER 2025, A HEALTHCARE FACILITY REPORTED VIA A FISHER & PAYKEL (F&P) FIELD REPRESENTATIVE THAT A PT101 AIRVO 2 HUMIDIFIER (AIRVO 2) SWITCHED OFF DURING USE. THE HEALTHCARE FACILITY DID NOT CONFIRM WHETHER THE SUBJECT DEVICE WAS UNPLUGGED OR IF MAINS POWER WAS LOST. ON 3 DECEMBER 2025, THE SUBJECT AIRVO 2 WAS RECEIVED AT THE FISHER & PAYKEL HEALTHCARE (F&P) REGIONAL OFFICE IN FRANCE WHERE IT WAS INSPECTED BY A TRAINED F&P SERVICE TECHNICIAN AND THE POWER OUT ALARM FUNCTIONALITY WAS CHECKED. DURING DEVICE EVALUATION AT THE F&P REGIONAL OFFICE IN FRANCE, IT WAS FOUND THAT THE POWER OUT ALARM OF THE SUBJECT DEVICE SOUNDED FOR LESS THAN 120 SECONDS. THIS WAS REPORTED SUBSEQUENT TO A FIELD SAFETY NOTICE INFORMING USERS OF A CHANGE TO THE DISINFECTION KIT USER MANUAL OF THE AIRVO 2 TO INCLUDE A REGULAR TEST OF THE POWER OUT ALARM, TO BE CARRIED OUT IN BETWEEN EACH PATIENT USE. THERE WAS NO REPORTED PATIENT INVOLVEMENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1716551 | FISHER & PAYKEL HEALTHCARE | RESPIRATORY HUMIDIFIER | BTT | FISHER & PAYKEL HEALTHCARE LTD | PT101EW | 2100751205 | 09420012422286 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | NA | Unknown |