K Number
K041223
Device Name
MODIFICATION TO SERVO-I VENTILATOR SYSTEM, MODEL 64 87 800 E407E
Date Cleared
2004-07-29

(80 days)

Product Code
Regulation Number
868.5895
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP Authorized
Intended Use
The Servo' Ventilator System is intended for treatment and monitoring of patients in the range of I ne or re Fentually with respiratory failure or respiratory insufficiency. Servo' is a ventilator neonales, thanks and datas will respiratery gain. I o realthcare facilities and for in-hospital transport.
Device Description
The ventilator is a platform with several selectable ventilation modes which monitor patients whom need respiratory assistance. The Non-Invasive Ventilation Option is a software controlled feature available on the Servo-i ventilator. The microprocessor control of this feature allows a larger range of flow capabilities designed to meet patient needs safely in a non-invasive application.
More Information

No
The document explicitly states "Mentions AI, DNN, or ML: Not Found" and the description focuses on microprocessor control and software features, not AI/ML algorithms.

Yes
The device is described as "intended for treatment and monitoring of patients with respiratory failure or respiratory insufficiency," which directly indicates a therapeutic purpose. It provides respiratory assistance, a form of therapy.

No.
The device is a ventilator intended for treatment and monitoring of patients with respiratory failure or insufficiency, not for diagnosing conditions.

No

The device description explicitly states it is a "ventilator," which is a hardware device. While it mentions a "software controlled feature" (Non-Invasive Ventilation Option), this feature is part of a larger hardware system.

Based on the provided information, this device is not an IVD (In Vitro Diagnostic).

Here's why:

  • Intended Use: The intended use clearly states the device is for "treatment and monitoring of patients... with respiratory failure or respiratory insufficiency." This describes a device used directly on a patient for life support and monitoring, not for testing samples outside the body.
  • Device Description: The description details a "ventilator" with "selectable ventilation modes" and "microprocessor control." This aligns with the function of a respiratory support device used on a patient.
  • Lack of IVD Characteristics: There is no mention of analyzing biological samples (blood, urine, tissue, etc.), detecting analytes, or providing diagnostic information based on laboratory testing.

IVD devices are designed to perform tests on samples taken from the human body to provide information for diagnosis, monitoring, or screening. This device's function is to assist with breathing and monitor respiratory parameters directly on the patient.

N/A

Intended Use / Indications for Use

The intended use(s) and indications of the Servo-i application, as described in its labelling, are the same as the intended uses and indications for the unmodified Servo-i, except for the intended population for Infant using the NIV option where the lower range is changed from 0,5 Kg to 3 KE:

The Servo' Ventilator System is intended for treatment and monitoring of patients in the range of I ne or re Fentually with respiratory failure or respiratory insufficiency. Servo' is a ventilator neonales, thanks and datas will respiratery gain. I o realthcare facilities and for in-hospital transport.

Product codes

CBK

Device Description

The ventilator is a platform with several selectable ventilation modes which monitor patients whom need respiratory assistance.

The Non-Invasive Ventilation Option is a software controlled feature available on the Servo-i ventilator. The microprocessor control of this feature allows a larger range of flow capabilities designed to meet patient needs safely in a non-invasive application.

To detect disconnect or excessive leakage there are two independent alarm functions:

  • an alarm will be given if the leakage is excessive. .
  • if the minimum PEEP will be unable to maintain (as in predicate device Servo-i) .

If leakage decreases the ventilation will resume automatically (or by manual start as in predicate Servo-i).

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

Not Found

Indicated Patient Age Range

from 0,5 Kg to 3 KE

Intended User / Care Setting

healthcare facilities and for in-hospital transport.

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Not Found

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Not Found

Predicate Device(s)

K040221, K010093

Reference Device(s)

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information for the subject device only (e.g. presence / absence, what scope was granted / cleared under the PCCP, any restrictions, etc).

Not Found

§ 868.5895 Continuous ventilator.

(a)
Identification. A continuous ventilator (respirator) is a device intended to mechanically control or assist patient breathing by delivering a predetermined percentage of oxygen in the breathing gas. Adult, pediatric, and neonatal ventilators are included in this generic type of device.(b)
Classification. Class II (performance standards).

0

JUL 2 9 2004

K041223

Section-Page

EVU-116506

Doc-ID

135 (140)

Issue no.

  • 00

| | | :
|
1 |
|--|--|-------|-------|
| | | | |

Object/Subject NIV option for Servo-i

510 (k) Summary

as required by section 807.92(c)

Subscribers Name & Address

Maquet Critical Care AB Röntgenvägen 2 SE-171 95 Solna, Sweden Tel: (011) 46 8 730 73 00 Fax: (011) 46 8 730 78 38

Contact Persons for this submission:

Mr. Anders Palm Tele. direct; (011) 46 8 730 74 88 Email: anders.palm@maquet.com

Document Type

Special 510(k)

USA Contact :

:

Mr. Jamie Yieh Manager, Regulatory Affairs Maquet Inc. 1140 Route 22 East, Suite 202 Bridgewater, NJ 08807 Phone: 908-947-2311 Fax: 908-947-2301 Cellphone; 908-227-8807 Email: jamie.yieh@maquet-inc.com

Trade Names

Servo-i Ventilator Systemarticle no.; 64 87 800 E407E
NIV optionarticle no.; 66 67 187 E407E
Device Classification
Common NameClassification
NumberClassRegulation Number
Ventilator, Continuous (Respirator)73 CBKII868.5895
Predicate Device Identification
Legally marketed devices to which equivalence is being claimed510(k) #
Servo-i Ventilatory SystemK040221
Evita 4, NIV optionK010093

1

| | Document Type
Special 510(k) | Section-Page | 136 (140) |
|------------------------|---------------------------------|--------------|-----------|
| Object/Subject | | Doc-ID | Issue no. |
| NIV option for Servo-i | | EVU-116506 | - 00 |

Device Description

The ventilator is a platform with several selectable ventilation modes which monitor patients whom need respiratory assistance.

Summary of technological characteristics of modified Device and Predicate Device: NIV option for Non -Invasive ventilation

The Non-Invasive Ventilation Option is a software controlled feature available on the Servo-i ventilator. The microprocessor control of this feature allows a larger range of flow capabilities designed to meet patient needs safely in a non-invasive application.

To detect disconnect or excessive leakage there are two independent alarm functions:

  • an alarm will be given if the leakage is excessive. .
  • if the minimum PEEP will be unable to maintain (as in predicate device Servo-i) .

If leakage decreases the ventilation will resume automatically (or by manual start as in predicate Servo-i).

Intended Use of the Device:

The intended use(s) and indications of the Servo-i application, as described in its labelling, are the same as the intended uses and indications for the unmodified Servo-i, except for the intended population for Infant using the NIV option where the lower range is changed from 0,5 Kg to 3 KE:

2

Image /page/2/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo is circular and contains the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" around the top half of the circle. Inside the circle is a stylized image of an eagle or bird with three curved lines representing its wings or body.

Public Health Service

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

JUL 2 9 2004

Maquet Critical Care AB C/O Mr. Jamie Yieh Manager, Regulatory Affairs Maquet, Incorporated 1140 Route 22 East, Suite 202 Bridgewater, New Jersey 08807

Re: K041223

Trade/Device Name: Modification to Servo-1 Ventilator System, Model 64 87 800 Regulation Number: 868.5895 Regulation Name: Continuous Ventilator Regulatory Class: II Product Code: CBK Dated: May 10, 2004 Received: May 10, 2004

Dear Mr. Yieh:

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.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to such additional controls. Existing major regulations affecting (1 wr ), ice 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.

3

Page 2 - Mr. Yieh

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); good manufacturing practice and if the (2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), nl Jase contact the Office of Compliance at (301) 594-4646. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). 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 (800) 638-2041 or (301) 443-6597 or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html

Sincerely yours,

Chiu Lin, Ph.D.

Chiu Lin, Ph.D. Director Division of Anesthesiology, General Hospital, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

4

MAQUET
Document Type
Special 510(k)Section-Page
28 (140)
Object/SubjectDoc-IDIssue no.
NIV option for Servo-iEVU-116506- 00

Indications for Use

510(k) Number (if known):

Device Name: Servo-i Ventilator System

Indications For Use:

INGICALONS I OF OSC.
The Servo' Ventilator System is intended for treatment and monitoring of patients in the range of I ne or re Fentually with respiratory failure or respiratory insufficiency. Servo' is a ventilator neonales, thanks and datas will respiratery gain. I o realthcare facilities and for in-hospital transport.

Prescription UseX
(Part 21 CFR 801 Subpart D)

AND/OR

Over-The-Counter Use
(21 CFR 807 Subpart C)

(Please do not WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Ouu Sulton

Page 1 of _

(Division Sign-Qff)
Division of Anesthesiology, General Hospital,
Infection Control, Dental Devices

510(k) Number: __

spital,