Jr. Gowardman et B. Moriarty, EXPLOSION AND FIRE IN THE EXPIRATORY LIMB OF A FISHER-AND-PAYKEL 3-IN-ONE-RESPIRATORY-CARE-SYSTEM, Anaesthesia and intensive care, 26(4), 1998, pp. 427-430
Citations number
5
Categorie Soggetti
Anesthesiology,"Emergency Medicine & Critical Care
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.