Patients with dysphagia often experience dehydration as a consequence of “nil by mouth” or having to consume thickened fluids due to aspiration of thin fluids. However, not all incidents of aspiration develop into an infection. Factors that contribute to aspiration pneumonia include poor oral care or the presence of oral/dental infections, poor physical mobility, compromised immunity, taking six or more medications, tube feeding, lack of independence with feeding and dental care, and reduced cognition and ability to adhere to safe swallow strategies. The Frazier free water protocol was developed to give selected dysphagic patients the option to drink water without thickener. It is suggested that the risk of developing aspiration pneumonia is reduced when drinking pure water compared to other fluids. In this protocol, patients may be allowed water 30 minutes after having a meal/thickened fluid and only after meticulous mouth-care to reduce the chance of bacteria being aspirated. Small amounts of aspiration of pure water may be easily absorbed into the bloodstream via the lungs without causing serious lung complications.

This systematic review examined the evidence for the use of the free water protocol. Eight studies (five RCTs) were included with a total of 245 participants for whom lung complications were monitored. Key findings from the review included the following: for patients on the free water protocol who were cognitively intact no aspiration pneumonia developed; there was evidence for the increase of hydration levels and quality of life scores were better.

The authors conclude that there is evidence (albeit low quality) to suggest that carefully selected dysphagic adult in-patients in rehabilitation settings should be given the choice to be on the free water protocol.

Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review.
Gilman, A, Winkler R, Taylor NF.
Roganie Govender

University College London, Head & Neck Academic Centre, UK.

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