The FDA has issued a Class 1 Recall Vapotherm® 2000i and 2000h Respiratory Gas Humidifiers. “Class 1 recalls are the most serious type of recall and involve situations in which there is a reasonable probability that use of the product will cause serious injury or death.”
According to the agency: “FDA has received reports of Vapotherm units becoming contaminated with Ralstonia spp, and other bacteria. Exposure to these bacteria may cause patients to develop tracheitis (infection of the trachea), sepsis (infection in the bloodstream), pneumonia (lung infection), or other serious infections. There is a reasonable probability that immunocompromised patients or premature newborns could develop pneumonia, sepsis and in the most severe cases, death.”
The Vapotherm 2000i and 2000h Respiratory Gas Administration delivers moisture to and warms breathing gases through a flexible nasal tube for patients receiving supplemental oxygen. The environments of use include home, hospital or sub-acute institutional settings.
The FDA makes the following suggestions with respect to the recall:
- “FDA recommends the use of alternative devices until the source of the contamination has been identified.
- In October 2005, Vapotherm issued new procedures for disinfecting the Vapotherm® 2000i and 2000h humidifiers, but these procedures have not been effective in eliminating Ralstonia spp. contamination in the devices.
- Patients who have been exposed to the Vapotherm system should be monitored for signs and symptoms that may suggest infection, which may include, but are not limited to:
- changes in temperature;
- poor feeding, irritability; and
- changes in hematologic indices.
Clinicians may want to consider Ralstonia infection in the differential diagnosis of symptomatic patients even if the organism has not been isolated.”
For additional information, see the FDA’s 12/20/05 Preliminary Public Health Notification at http://www.fda.gov/cdrh/safety/122005-vapotherm.html.