Missed chewing gum aspiration despite intubation with a videolaryngoscope: A case report

Fasting before anaesthesia is important to prevent aspiration of gastric content, but patients may not be aware that chewing gum must be removed before surgery. We report the aspiration of chewing gum that was missed despite the use of a videolaryngoscope while under the observation of two anaesthetists. Written informed consent for this report was obtained from the patient.

A 42-year-old healthy female patient was scheduled for semi-urgent cervical spine surgery after a fall from height. She was instructed to fast before surgery according to standard guidelines. Before anaesthesia she was asked if she was fasting, but not specifically if she was chewing gum. Videolaryngoscopy (GlideScope AVL; Verathon Inc., Seattle, WA, USA) was performed under the observation of a second anaesthetist and was easy and uneventful, as was surgery and anaesthesia. After removal of the tracheal tube at the end of anaesthesia, a greyish, sticky substance was seen on the cuff and below it, covering a part of the Murphy eye (Figure 1). The patient confirmed that she was chewing gum when entering the operating room. Subsequent fibreoptic bronchoscopy revealed no remains of the chewing gum and no damage to the trachea or the bronchial tree.

Figure 1.

Chewing gum glued to the cuff of the tracheal tube and below it, covering part of the Murphy eye.

Tracheal aspiration of chewing gum during anaesthesia seems to be a rare event. Shanumgam et al. searched in the anaesthesia incident reporting system from the Australian and New Zealand Tripartite Anaesthetic Data Committee incidence database from 2009 to 2015, and found only one case out of 2600 reports when chewing gum was found on direct laryngoscopy in the vicinity of the vocal cords. ¹ In one case chewing gum was found on the laryngeal mask airway and in two cases patients were found to be chewing gum in the recovery room after ‘hiding’ the gum behind their molars. Few case reports on tracheal aspiration of chewing gum have been published, and none mentioned the possibility that the gum was missed during laryngoscopy. ¹

It is well known that patients have difficulties understanding and remembering all the instructions they receive from healthcare workers. ² , ³ This is in part due to the instructions’ complexity and ambiguity, such as in the case of fasting instructions. Telling patients ‘you have to fast before surgery’ is too vague and going into the details concerning preoperative fasting orders can easily fail. ⁴ The American Society of Anesthesiologists fasting guidelines for adults are complicated: ⁵ fasting time of solid food varies between six and eight hours, depending on the different types of food and the amount of food ingested. Also, the definitions of the food types are open to interpretation (such as ‘fatty food’, which can be interpreted differently). Chewing gum is not mentioned at all. In contrast, the fasting recommendations of the European Society of Anaesthesiology (ESA) for solid food in adults are simple: ⁶ ‘6 hours’, without mentioning any type of food. The ESA guidelines recommend not to cancel surgery if a patient was chewing gum.

According to the guidelines of the Israeli Ministry of Health, patients must be questioned as to whether they fasted immediately before the start of anaesthesia (during ‘sign in’). ⁷ Although this was done in our patient, we speculate two possible reasons why the chewing gum was missed. Firstly, the patient may not have understood that ‘fasting’ includes avoiding chewing gum. Secondly, she may have felt embarrassed to admit that she had chewing gum in her mouth without being aware that this could endanger her life.

In summary, chewing gum aspiration is rare but potentially very dangerous, and can be missed even when intubation is performed with a videolaryngoscope. Patients should be instructed to remove chewing gum before surgery, and this should be assessed by targeted questioning immediately before the induction of anaesthesia.