Rubber Universal Breathing-Circuit Adapters: Risk of Increased Disconnections
Hazard [Health Devices Nov 1991;20(11):444]
Breathing-circuit disconnections have
resulted in patient injury and death. With the widespread use of
standard conical fittings, which meet the current American Society of Testing and Materials (ASTM)
Standard F1054-87, breathing-circuit disconnections and the hazards they cause have become
rare; when they do occur, they are usually detected by alarms. Although conical fittings
can be engaged tightly enough to resist disconnection from most normally encountered
forces, some users continue to use soft rubber universal adapters (which stretch to fit
different sizes and types of connectors) in patient circuits; these adapters do not meet
the ASTM standard and are prone to disconnection.
Most universal adapters can resist considerable axial force before
disconnecting; however, they can be easily disconnected by even small off-axis forces.
Also, unlike standard conical 15 and 22 mm fittings, it is possible to misassemble some
other type of circuit into a breathing circuit when universal adapters are used.
- Discontinue using universal adapters or other soft
rubber components in breathing circuits and other special circuits that are
used with patients.
- Always use an exhaled-volume or a CO2
monitor to detect leaks and disconnections of breathing circuits.
- Breathing Circuit Adapters [10-123]
- Breathing Circuits, Anesthesia [10-139]
- Breathing Circuits, Ventilator 
Cause of Device-Related Incident
Device factor: Design/labeling error
User errors: Accidental misconnections; Device
misassembly; Failure to perform pre-use inpection; Improper connection
Mechanism of Injury or Death