Adult Swallowing EBP Group
EBP Extravaganza
13 th December 2012

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Free Water Protocol
Clinical question
What is the free water protocol
Good oral hygiene is critical
CAPs
CATs
Clinical Application

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In patients with dysphagia what are the benefits and complications of implementing the free water protocol?

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A protocol to regulate the provision of water to patients known to aspirate thin fluids.
Strict guidelines are outlined with regards to suitability of the patient (e.g. Not suitable for patients with extreme coughing).
It involves:
Strict oral hygiene
Water is permitted between meals (not during or until 30 minutes after).
No water given with medications.
AIM: Increase quality of life, hydration and compliance, whilst maintaining safety.

Dysphagia & pneumonia: a complex relationship (Langmore 1998)
Colonisation (altered oropharyngeal flora):
Aspiration into lungs
Host resistance
Pneumonia

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Carlaw, C., Finlayson, H., Beggs,K., Visser, T., Marcoux, C., Coney,
D. & Steele, C.M. (2011) Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia (published on-line).
Scott, A., & Benjamin, L. (2010). Implementation of a free fluid protocol in an aged care facility. In Roddam, H., & Skeat, J. (eds).
Embedding evidence based practice in speech and language therapy.
West Sussex: Wiley-Blackwell.
Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral intake of water in patients with oropharyngeal dysphagia. BMC
Geriatrics, 11:9.
Panther, K. (2005). The Frazier Free Water Protocol. Swallowing
and Swallowing Disorders, March:4-9.
Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control study to determine the effects on unlimited oral intake of water in patients with identified aspiration. Journal of Neurological
Rehabilitation, 11: 139-148.

Article
Carlaw et. al
(2011)
Level
2
Participant
16
CVA Spinal cord
TBI
Method
Randomisation
Immediate and delayed implementation
Outcome measures
Fluid intake
SwallQoL
Adverse event
Results
Increase
Improved
Nil
Support
Yes
Scott &
Benjamin
(2010)
Karagianis et. al (2011)
4
3
Panther
(2005)
Garon et. al.
(2007)
4
2
26
ACF
76
Subacture and mixed etiologies
234
Acute rehab
20
Stroke rehabilitation
Implemented FWP Adverse event
Control group – usual care
Experimental group
– implemented
FWP
Implemented FWP
Fluid intake
SwallQoL
Adverse event
Implemented FWP
Aspiration
Pneumonia
Averse events
Fluid intake
Nil
Increased
Improved
14.3% developed asp pneu
2 participants
Nil
Increased
Yes
Inconclusive
Yes
Yes

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In patients with dysphagia, what are the benefits and complications of implementing the Free
Water Protocol?
Four studies using a free water protocol with medically stable participants in the rehabilitation and residential aged care settings found nil evidence of adverse events while benefits such as increased fluid intake and improved quality of life measures were indicated. Due to methodological limitations of the study involving acute patients, there is insufficient evidence to support the use of the Free Water Protocol in acute settings.

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Importance or oral hygiene
Considering your site when implementing the protocol
Considering patients when implementing the protocol
The need for MBS

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Carlaw, C., Finlayson, H., Beggs,K., Visser, T., Marcoux, C., Coney, D. & Steele, C.M. (2011) Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia (published on-line).
Crary, M.A., Giselle, D., Carnaby, M., Groher, M.E., & Helseth, E. (2004). Functional benefits of dysphagia therapy using the adjunctive sEMG biofeedback. Dysphagia,
Crary, M.A., & Baldwin, B.O. (1997). Surface electromyographic characteristics of swallowing in dysphagia secondary to brainstem stroke. Dysphagia,
Crary, M.A. (1995). A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. Dysphagia, 10:6-8.
Garon, B., Engle, M., & Ormiston, C. (1997). A randomised control study to determine the effects on unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation,
11: 139-148.
Huckabee, M.L. & Cannito, M.P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia,
Karagianis, M.J.P., Chivers, L., Karagianis, C. (2011). Effects or oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11:9.
Langmore, S.E., Terpenning, M.S., Shork, A., Chen, Y., Murray, J.T., Lopatin, D., Loeshe, W.J. (1998).
Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13: 69-81.
Panther, K. (2005). The Frazier Free Water Protocol. Swallowing and Swallowing Disorders, March:4-9.
Newlove, S. (2006). A case study examining the effectiveness of surface electromyography biofeedback in dysphagia rehabilitation and SWAL_QOL quality of life outcome measure. (Research Project, University of Auckland).
Scott, A., & Benjamin, L. (2010). Implementation of a free fluid protocol in an aged care facility. In
Roddam, H., & Skeat, J. (eds). Embedding evidence based practice in speech and language therapy. West
Sussex: Wiley-Blackwell.