EXPLOSION AND FIRE IN THE EXPIRATORY LIMB OF A FISHER-AND-PAYKEL 3-IN-ONE-RESPIRATORY-CARE-SYSTEM

We report an incident involving a Fisher and Paykel ''Three in One Res piratory Care System'' (Fisher and Paykel Healthcare, Auckland, New Ze aland). This is a new ventilator circuit designed to be adaptable to t he needs of ventilator intubated CPAP, and mask therapies. In this cas e the patient had received eight hours of CPAP therapy overnight, duri ng which time the ''Three in One'' circuit had Seen broken down to the CPAP configuration. The expiratory limb heater element, normally disc onnected, was inadvertently left connected to the heater base. Under t he extreme conditions of hearing under ''no gas flow'' mode, the heate r element malfunctioned. As a result when the circuit was reconfigured to provide pressure-supported ventilation in the high oxygen environm ent of the expiratory limb (FiO(2) 0.5), ignition and combustion of th e respiratory circuit occurred The case is reported because of the pot entially serious consequences and because the incident prompted the ma nufacturer to redesign and change componentry in parts of the circuit implicated.