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Don’t Burn Your Tongue..Hot Topics in
Dysphagia: Free Water Protocol and sEMG
Adult Swallowing EBP Group
EBP Extravaganza
13th December 2012
Presentation Outline

-
Free Water Protocol
Clinical question
What is the free water protocol
Good oral hygiene is critical
CAPs
CATs
Clinical Application
Free Water Protocol: Clinical Question

In patients with dysphagia what are the benefits
and complications of implementing the free
water protocol?
Free Water Protocol: What is it?
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.
Free Water Protocol:
Good Oral Hygiene is Critical
Dysphagia & pneumonia: a complex relationship (Langmore 1998)
Colonisation (altered oropharyngeal flora):
Aspiration into lungs
Host resistance
Pneumonia
Free Water Protocol CAPs





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.
Free Water Protocol CAP summary
Article
Level
Participant
Method
Outcome
measures
Results
Support
Carlaw et. al
(2011)
2
16
Randomisation
Fluid intake
Increase
Yes
CVA Spinal
cord
SwallQoL
Improved
Adverse event
Nil
TBI
Immediate and
delayed
implementation
26
Implemented FWP
Adverse event
Nil
Yes
Control group –
usual care
Fluid intake
Increased
Inconclusive
SwallQoL
Improved
Experimental group
– implemented
FWP
Adverse event
14.3%
developed
asp pneu
Implemented FWP
Aspiration
Pneumonia
2
participants
Yes
Implemented FWP
Averse events
Nil
Yes
Fluid intake
Increased
Scott &
Benjamin
(2010)
4
Karagianis
et. al (2011)
3
ACF
76
Subacture
and mixed
etiologies
Panther
(2005)
4
Garon et. al.
(2007)
2
234
Acute rehab
20
Stroke
rehabilitation
Free Water Protocol: CAT

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.
Free Water Protocol: Clinical Applications
Importance or oral hygiene
 Considering your site when implementing the
protocol
 Considering patients when implementing the
protocol
 The need for MBS

References

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.
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