RT016 INSPIRATORY FILTER

K133666 · Fisher & Paykel Healthcare, Ltd. · CAH · Feb 5, 2014 · Anesthesiology

Device Facts

• Record ID: K133666
• Device Name: RT016 INSPIRATORY FILTER
• Applicant: Fisher & Paykel Healthcare, Ltd.
• Product Code: CAH · Anesthesiology
• Decision Date: Feb 5, 2014
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 868.5260
• Device Class: Class 2

Indications for Use

The Fisher & Paykel Healthcare RT016 Inspiratory Filter is intended for use between a ventilator and breathing circuit. Its function is to remove microbiological and particulate matter from gases entering a breathing circuit. The RT016 is intended to the ventilator inspiratory port. It is not directional in terms of flow and is a single use device.

Device Story

The RT016 Inspiratory Filter is a single-use, non-sterile breathing circuit filter designed for placement at the ventilator inspiratory port. It utilizes depth-type, electrostatic, hydrophobic media housed within a 22 mm connector assembly to trap microbiological and particulate matter from dry inspiratory gases. The device functions as a passive barrier to protect the breathing circuit from contaminants. It is intended for use in clinical settings where mechanical ventilation is required. The healthcare provider installs the filter between the ventilator and the breathing circuit; the filter's presence ensures that gases delivered to the patient are filtered. The device does not require active operation or monitoring. By removing particulates and microbes, it reduces the risk of contamination within the breathing circuit, potentially benefiting the patient by preventing the delivery of pathogens or debris during mechanical ventilation.

Clinical Evidence

No clinical testing was performed. Substantial equivalence is supported by bench testing of filtration efficiency (bacterial >99.9997%, viral >99.99%, salt test 98.17%) and physical performance characteristics (flow resistance, compliance, internal volume, gas leakage) compared to the predicate device.

Technological Characteristics

Materials: Filter media (depth-type, electrostatic, hydrophobic), housing (22 mm connectors). Standards: ISO 5356-1:2004 (connectors), BS EN ISO 23328-1:2008 (salt test). Form factor: 22 mm female/male connectors. Sterility: Non-sterile. Connectivity: None (mechanical).

Indications for Use

Indicated for use between a ventilator and breathing circuit to remove microbiological and particulate matter from gases entering the circuit via the ventilator inspiratory port. Single-use device for prescription use.

Regulatory Classification

Identification

A breathing circuit bacterial filter is a device that is intended to remove microbiological and particulate matter from the gases in the breathing circuit.

Predicate Devices

• RT019 Inspiratory/Expiratory Filter (K050927)

Submission Summary (Full Text)

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510(k) Notification 5-1

K733666

### 510(k) Summary 5

FEB - 5 2014

Image /page/0/Picture/5 description: The image shows the logo for Fisher & Paykel Healthcare. The words "Fisher & Paykel" are on the top line in a bold, sans-serif font. The word "HEALTHCARE" is on the second line, also in a bold, sans-serif font.

15 Maurice Paykel Place, East Tamaki P O Box 14 348, Panmure Auckland, New Zealand Telephone: [phone] Facsimile: [phone] Website: www.fphcare.com

| Contact person/submitter | Elizabeth Goldstein |
|--------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------|
| Date prepared | 27 November 2013 |
| Contact details | Address: 15 Maurice Paykel Place<br>Paykel Building<br>East Tamaki<br>Auckland 2013, New Zealand<br><br>Telephone: [phone]<br>Fax: [phone] |
| Trade name | RT016 Inspiratory Filter |
| Common name | Breathing circuit bacterial filter |
| Classification name | Breathing circuit bacterial filter<br>Class II (21 CFR §868.5260)<br>Product code CAH (Filter, Bacterial, Breathing-Circuit) |
| Predicate device | RT019 Inspiratory/Expiratory Filter (K050927) |

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## 5.1 Device Description

The Fisher & Paykel Healthcare RT016 Inspiratory Filter is intended for use between a ventilator and breathing circuit. Its function is to remove microbiological and particulate matter from gases entering a breathing circuit. The RT016 is intended to the ventilator inspiratory port. It is not directional in terms of flow and is a single use device.

The filter is comprised of a female (22 mm) filter housing, filter media and male (22 mm) filter housing. The filter media is a depth-type, electrostatic, hydrophobic media which traps microbiological and particulate matter. The filter media is held in place between the female and male filter housings. Both the female and male filter housings have standard 22 mm diameter connectors which have been designed to comply with ISO 5356-1.

## 5.2 Indications for Use

The Fisher & Paykel Healthcare RT016 Inspiratory Filter is intended for use between a ventilator and breathing circuit. Its function is to remove microbiological and particulate matter from gases entering a breathing circuit. The RT016 is intended to the ventilator inspiratory port. It is not directional in terms of flow and is a single use device.

# 5.2.1 Indications for Use Comparison

The indications for Use Statements of the subject device, RT016 Inspiratory Filter, and the predicate device. RT019 Inspiratory/Expiratory Filter (K050927), are identical with the exception of the following:

- The placement of the filter with a ventilator system, where: :
- o The subject device, RT016 Inspiratory Filter, is intended to be connected to the ventilator inspiratory port only.
- The predicate device, RT019 Inspiratory/Expiratory Filter (K050927), may be o connected to the ventilator inspiratory and/or the ventilator expiratory port.

This change in configuration does not raise any new questions of safety or effectiveness for the following reasons:

- . The placement of the RT016 Inspiratory Filter on the ventilator inspiratory port is also an approved configuration for the predicate device.
- The RT016 Inspiratory Filter labelling clearly identifies the device as an . inspiratory filter and shows the RT016 Inspiratory Filter connected to the ventilator inspiratory port.

Refer to Table 5.1 on the following page for a side-by-side comparison of the Indications for Statements of the subject and predicate devices.

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| Design/technological<br>characteristic for<br>comparison | Subject device<br>(RT016 Inspiratory Filter) | Predicate device<br>(RT019<br>Inspiratory/Expiratory<br>Filter, K050927) | Comments |
|----------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Indications for use | • The Fisher & Paykel<br>Healthcare RT016<br>Inspiratory Filter is<br>intended for use between<br>a ventilator and breathing<br>circuit. | • The Fisher & Paykel<br>Healthcare RT019<br>Inspiratory/Expiratory<br>Filter is intended for use<br>between a ventilator and<br>breathing circuit. | Identical |
| | • Its function is to remove<br>microbiological and<br>particulate matter from<br>gases entering a breathing<br>circuit. The RT016 is<br>intended to be connected<br>to the ventilator<br>inspiratory port. | • Its function is to remove<br>microbiological and<br>particulate matter from<br>gases entering and/or<br>exiting a breathing circuit.<br>The RT019 is intended to<br>be connected to the<br>ventilator inspiratory<br>and/or expiratory ports. | Identical<br>The function of the<br>subject device and<br>predicate device is<br>identical.<br>However the subject<br>device is intended to<br>be connected to the<br>ventilator inspiratory<br>port only, whereas<br>the predicate device<br>may be connected to<br>the ventilator<br>inspiratory and/or<br>expiratory ports. |
| | • It is not directional in<br>terms of flow and is a<br>single use device. | • It is not directional in<br>terms of flow and is a<br>single use device. | Identical |
| | • Availability: prescription<br>use (Part 21 CFR 801<br>Subpart D) | • Availability: prescription<br>use (Part 21 CFR 801<br>Subpart D) | Identical |

Table 5.1 A comparison of the Indications for Use of the subject and predicate devices

# 5.3 Technological Characteristics Comparison

The subject device, RT016 Inspiratory Filter, is identical to the predicate device, RT019 Inspiratory/Expiratory Filter (K050927), with respect to the following technological characteristics:

- Function, i.e. to remove microbiological and particulate matter from gases, as per the . Indications for Use.
- Reusability (i.e. single use) and sterility (i.e. non-sterile). .
- . Design:
- o All components of the RT016 Inspiratory Filter are identical to the corresponding components of the RT019 Inspiratory Expiratory Filter, including materials and processing;
- Performance (i.e. filtration efficiency). .

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The subject device, RT016 Inspiratory Filter, differs from the predicate device, RT019 Inspiratory/Expiratory Filter (K050927), in that:

- The predicate device, RT019 Inspiratory/Expiratory Filter (K050927), has insulation . housing to reduce condensation when used on the ventilator expiratory port (i.e. used with gases which are warm and humid), whereas the RT016 Inspiratory Filter does not have an insulation case as it is used on the ventilator inspiratory port only (i.e. on gases which are dry).
Refer to Table 5.2 for a side-by-side comparison of the key technological characteristics of the subject device, RT016 Inspiratory Filter, and the predicate device, RT019 Inspiratory/Expiratory Filter (K050927).

| Design/technological<br>characteristic for<br>comparison | Subject device<br>(RT016 Inspiratory Filter) | Predicate device<br>(RT019<br>Inspiratory/Expiratory<br>Filter, K050927) | Comments |
|----------------------------------------------------------|--------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Configuration | Connected to the<br>ventilator inspiratory<br>port | Connected to the<br>ventilator inspiratory<br>port Connected to the<br>ventilator expiratory<br>port | Identical<br>As per the Indications<br>for use, the subject<br>device is intended to<br>be connected to the<br>ventilator inspiratory<br>port only. |
| Reusability | Single use only | Single use only | Identical |
| Components | Female (22 mm) filter<br>housing; Filter media; Male (22 mm) filter<br>housing | Female (22 mm) filter<br>housing; Filter media; Male (22 mm) filter<br>housing; Male insulation casing; Female insulation<br>casing | Identical<br>All components used<br>in subject device are<br>identical to the<br>corresponding<br>components used in<br>the predicate device,<br>including identical<br>materials and<br>processing.<br>The subject device<br>does not include the<br>male or female<br>insulation casing<br>components. |
| Connectors | Standard 22 mm<br>connectors Designed to comply<br>with<br>ISO 5356-1:2004 | Standard 22 mm<br>connectors Designed to comply<br>with<br>ISO 5356-1:2004 | Identical |

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| Design/technological<br>characteristic for<br>comparison | Subject device<br>(RT016 Inspiratory Filter) | Predicate device<br>(RT019<br>Inspiratory/Expiratory<br>Filter, K050927) | Comments |
|----------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------|
| Sterility | Supplied in a non-sterile state Non-sterile when used | Supplied in a non-sterile state Non-sterile when used | Identical |
| Filtration efficiency | Bacterial: >99.9997% Viral: >99.99% Salt test: 98.17% | Bacterial: >99.9997% Viral: >99.99% Salt test: 98.17% | Identical |
| Technical<br>specifications | Resistance to flow:<br>$0.35 \pm .06$ cmH2O at 15 L/min $0.71 \pm 0.12$ cmH2O at 30 L/min Internal volume (i.e. compressible volume): 38 mL Compliance: 0.13 mL/cmH2O Gas leakage: <5 mL/min at $70 \pm 3.5$ cmH2O | Resistance to flow:<br>$0.35 \pm .06$ cmH2O at 15 L/min $0.71 \pm 0.12$ cmH2O at 30 L/min Internal volume (i.e. compressible volume): 38 mL Compliance: 0.13 mL/cmH2O Gas leakage: <5 mL/min at $70 \pm 3.5$ cmH2O | Identical |

Table 5.2 A comparison of the key technological characteristics of the subject and predicate devices

# 5.4 Non-Clinical Tests

The RT016 Inspiratory Filter and the predicate device, RT019 Inspiratory/Expiratory Filter (K050927), share the same filter media component and therefore the non-clinical tests summarized below are applicable to both devices.

The following performance characteristics of the filter media were tested:

- Bacterial filtration efficiency; .
- Viral filtration efficiency; and .
- Filtration efficiency as per the salt test method specified in BS EN ISO 23328-1:2008. .

The results of the performance testing are as follows:

- . Bacterial filtration efficiency: >99.9997%;
- . Viral filtration efficiency: >99.99%; and
- . Filtration efficiency as per the salt test method (NaCl): 98.17%.

The filtration of the two devices shows that the filtration performance is identical.

# 5.5 Clinical Tests

.

Not applicable - no clinical testing was performed with respect to the RT016 Inspiratory Filter.

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#### 5.6 Conclusion

The comparison of the technological characteristics summarized above demonstrates that the subject device, RT016 Inspiratory Filter, is substantially equivalent to the predicate device, RT019 Inspiratory/Expiratory Filter (K050927). In addition, bench testing, as summarized above, supports both performance of the RT016 Inspiratory Filter in accordance with its intended use as well as substantial equivalence of the RT016 Inspiratory Filter to the RT019 Inspiratory/Expiratory Filter (K050927).

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## DEPARTMENT OF HEALTH & HUMAN SERVICES

Image /page/6/Picture/1 description: The image shows the logo for the U.S. Department of Health and Human Services. The logo features a stylized caduceus symbol, which is a staff with two snakes coiled around it. The words "DEPARTMENT OF HEALTH & HUMAN SERVICES • USA" are arranged in a circular pattern around the caduceus symbol. The logo is black and white.

#### Public Health Service

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

February 5, 2014

Fisher & Paykel Healthcare Elizabeth Goldstein Regulatory Affairs Specialist 15 Maurice Paykel Place Paykel Building East Tamaki Auckland, New Zealand 14 348

Re: K133666

Trade/Device Name: RT016 Inspiratory Filter Regulation Number: 21 CFR 868.5260 Regulation Name: Breathing Circuit Bacterial Filter Regulatory Class: Class II Product Code: CAH Dated: November 27, 2013 Received: November 29, 2013

Dear Ms. Goldstein:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

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Page 2 - Ms. Elizabeth Goldstein

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Small Manufacturers, International and Consumer Assistance at its tollfree number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

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Erin Keith Acting Division Director Division of General Hospital, Respiratory, Anesthesiology Infectious Control, and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

## Indications for Use

510(k) Number (if known)

K133466

Device Name RT016 Inspiratory Filter

### Indications for Use (Describe)

The Fisher & Paykel Healthcare RTD16 Inspiratory Fitter is intended for use between a ventilator and breathing circuit. Its function is to remove microbiological and particulate matter from gases entering a breathing circuit. The RT016 is intended to the ventilator inspiratory port. It is not directional in terms of flow and is a single use device.

Type of Use (Select one or both, as applicable)

> Prescription Use (Part 21 CFR 801 Subpart D)

_ Over-The-Counter Use (21 CFR 801 Subpart C)

# PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON A SEPARATE PAGE IF NEEDED.

CARDE OF COLLECTION OF FOR FDALUSE ONLY . STOREDAL CONSULT AND AND AND Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)

FDA

Anya C. Harry -S 2014.01.29 19:31:18 -05'00'

FORM FDA 3881 (9/13)

PSC Publishung Scrices [phone]

Form Approved: OMB No. 0910-0120 Expiration Date: December 31, 2013 See PRA Statement on last page.