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History of FWP

Frazier Rehab’s water protocol was implemented in 1984 as a response to non-compliant patients who were covertly consuming thin liquids or refusing to drink thickened liquids.

- The key is to listen to your patients

- Thickened liquids became the key without an evidence, but pts. started cheating (and we told them they would get pneumonia)

- Pts. didn’t believe SLPs knew what they were talking about in regards to thickened liquids, so they were noncompliant

- In 1984 many of our patients refused to believe they were going to get pneumonia.

- As we observed that many did not, we felt the need to alter our approach to strict dysphagia intervention.

- Non-compliant patients were not developing aspiration pneumonia despite evidence of aspiration on videofluoroscopy.


Basis of the FWP

- FWP allows thin liquid aspirators to drink water.

- Anytime during the day as long as it is not during meals or 30 mins after a meal

- compromise to thick liquids


False belief about aspiration

all aspirating patients were at risk of developing aspiration pneumonia was held.


Who created the FWP

The Frazier Water Protocol was developed through the inter-disciplinary cooperation of physicians, speech-language pathologists and a dietitian.


Dr. Judah Skolnick


- Stated that water was safe because:

1. The body is approximately 60% water.

2. Tap water is a near neutral pH and so is compatible with other body fluids.

3. Tap water will not cause a chemical injury as might be expected with liquids such as soda, tea, or coffee.

4. If a drink of water is aspirated it will be absorbed by the lung mucosal tissue without harm.

5. Unlike an aspirated green bean or bite of chicken, water does not obstruct the airway. (water will travel through)



- Up to 60% of human body = water

- 70% of brain = water

- 90% of lungs = water

- WATER ONLY! Not other liquids

- A volume of 25 ml of highly acidic contents carries more risk than pH neutral fluids of the same volume. (Schwartz, 1980)

- Most municipal tap water is a nearly neutral pH and very close to the pH of bodily fluids (pH = 7.2).

- Therefore, the presence of water in the pulmonary system should not cause a chemical injury to the mucosa of the lungs


Absorption of fluid in the lungs

- The ability of the lung to rapidly absorb water is well known.

- Aquaporins are water conducting channels in the lung endothelium and epithelium. (in all organ tissues)

- Water aspirated during fresh water swimming or drinking is rapidly absorbed from the airspaces


Why is there scant evidence of the safety of allowing thin liquid aspirators to drink water?

- Hindsight is 20-20

- 2000-3000 subjects needed to empirically prove safety of water (difficult and costly)

- Funding limitations


Evidence based research water protocols: Garon

•20 stroke patients known to aspirate thin liquids

- None of the patients in the control group reported satisfaction with thickened liquids and all reported a desire for water or ice chips to quench thirst. Garon et al. found patients who were allowed water expressed a high degree of satisfaction and reported thickened liquids did not quench thirst.

- Nobody got pneumonia, dehydration or other complications

•Free-water subjects reached “no aspiration” status faster (33 days) than control subjects (39 days) [no statistical comparison of this variable]


Evidence based research water protocols: Bronson-Lowe

Conclusion: In this study, the FWP did not exacerbate the risk of pneumonia.


Evidence based research water protocols:

Explored impact of water protocols on adverse event rates; recovery trajectories and length-of-stay. 15 participants and 11 controls.

•Participants were confirmed aspirators on liquid in VFSS

•Mean hospitalization dramatically shorter in water protocol patients.


Evidence based research water protocols:


16 participants enrolled (7 controls- delayed implementation group)

•All participants had confirmed dysphagia for thin liquids on VFSS at baseline (13 were penetrators or aspirators)

•6 of the controls subsequently crossed-over to water protocols

•No adverse events (pneumonia; acute-care hospitalizations) experienced by any participants.


Evidence Base for Water Protocols- GF Strong

GF Strong has developed a “supervised protocol” for those unable to take water independently. 

Exclusion:  active PNA (pnuemonia); absent swallow reflex; uncomfortable cough.

Conclusion: Results of this trial to-date suggest that the GF Strong water protocol can be safely implemented in rehabilitation settings, with positive outcomes in hydration and quality-of-life.

*** in the early days of dysphagia, quality of life was not considered


Evidence based research water protocols:

The results support the safe intake of water by persons with CVA and dysphagia admitted to acute neurorehabilitation who are restricted to thickened liquids.


Evidence based research water protocols:


- The adverse effects developed in patients with severe neurodegenerative disease.

- These patients were bedridden and dependent for feeding or were limited in mobility.

- Researchers recommended water not be permitted to acute patients, patients with severe neuro conditions, and immobility.
QOL was improved for patients allowed water as compared to the controls.

- Recommend subacute patients with relatively good mobility should have choice after being well-informed of the relative risk.

- Current findings do not obviate the need to deviate from the FWP.


Cochrane Review

Allowing children who have thin fluid aspiration to drink water may assist in providing enough fluid without endangering the lung.”


1. Aspiration Pneumonia Incidence Study at Frazier

2. Dehydration Incidence

1. Two of the 234 patients developed aspiration pneumonia (.9%). Both were suspected of aspirating solid foods.

2. In the same chart reviews of 234 inpatients, we found five cases of dehydration severe enough to require IV fluids.


Frazier Water Protocol Methods

- Thickened liquids are recommended and provided, but water is permitted between meals.

- Between meals only, because if you were to aspirate the water while eating a meal, the food could be aspirated with it and then the pt. would have a chance of getting pneumonia

- Compensation techniques are also used with water, because aspirating is not pleasant and pts. are not good about at keeping the techniques up

- Interventions to minimize aspiration of water as well as thickened liquids and foods are provided therapeutically.

- Compensatory maneuvers and behaviors are taught to patients, families and staff as is deemed appropriate for each patient.


Informed recommendations

The clinician should be sure that the water source is safe.

* If the water is not safe, use bottled water

- Clinicians who decide to pursue allowing dysphagic patients to drink water should be aware of the risks and benefits, and be prepared to make informed recommendations.

- The dysphagia clinician should also make an independent consideration of the patient population served.

---You have to think about the patients, think about quality of life, what are their disorders?

--- There is a very high correlation between tube feeding and aspiration


Informed Recommendations- for acute care pts.

- Water is recommended for acute care patients on a case-by-case basis and require physician orders for the initiation of water intake.

- The order is written as “Frazier Water Protocol”.

- Ice chips are more likely the first step toward allowing water in our acute care setting.


Frazier Water Protocol Guidelines

The guidelines have been tailored to meet the needs of the patients served in this rehab facility. At Frazier, all dysphagic patients are allowed water. An order is required to NOT allow water.

- All patients referred to speech-language pathology are screened with water on the initial bedside visit to the patient.

- Even if the pt. is not coming in with signs of dysphagia

- Instrumental swallow exams to determine pathophysiology of dysphagia are conducted on nearly all dysphagic patients referred to speech-language pathology.

- Results of the exams contribute to treatment planning for dysphagic intervention.


Frazier Water Protocol Guidelines

- The purpose of the screening (3)

- to determine if patients are demonstrating signs and symptoms of dysphagia;

- to check for level of alertness and presence of impulsivity;

- and to decide if further dysphagia evaluation is warranted.


The SLPs conduct dysphagia therapy per intervention approaches that include:

- Intervention as usual***

1. sensory behavioral techniques

2. motor behavioral techniques

3. postural compensations

4. facilitating maneuvers

- Sensory – sensory awareness thru pressure, temp stimulation as well as bolus size and texture manipulation


Frazier Water Protocol Guidelines

- impulsivity or excessive coughing

- Patients exhibiting impulsivity or excessive coughing and discomfort will be restricted to water taken under supervision.

--- Give them a very controlled amount

Supervision is needed for super coughers

- When the pt. aspirates, they cough so hard, their eyes water, and there is pain involved

- Patients with extreme choking may not be permitted oral intake of water due to the physical discomfort of coughing. This is a rare occurrence.

- Occasionally, a physician may order strict NPO for a patient and water or ice chips will not be permitted.


Pts. on oral diets with thickened liquids (FWP)

For patients on oral diets, water is permitted between meals. The prescribed thickened liquid is used during meals.


Enterally fed pts. (FWP)

- Enterally fed patients are permitted water any time.

- (Tube feed patients) *** can have water anytime because there is no chance that they will aspirate food.


FWP compensations

Patients for whom compensations, e.g. chin tuck, head turn, etc., have proven to be successful are encouraged to use compensations while drinking water.


Checking dysphagia progress with FWP

- Water gives opportunity to clinically check a patient’s progress, to judge when a patient may be ready to have a diet advanced.

- Progresses pts. faster

- More than just better hydration and better quality of life

- Easy to measure when a pt. maybe able to have thin liquids because they are only aspirating 1 out of 10 drinks

- Not just randomly picking a date to do another swallow study, you have evidence

- Patients sip water during therapy sessions while the SLP watches for changes in the cough response.

- SLPs use the presence and frequency of a cough to gauge swallowing progress.


Oral Care and Dysphagia

Aggressive oral care should be provided to those patients who are unable to clean their own teeth and mouths so that pathogenic bacteria are less likely to contaminate secretions. Oral care should be done before the first meal of the day.

- High incidence of pneumonia related to an unclean mouth (oral bacteria) so oral care is very important

- We educate on oral care, but we are not doing the oral care, the nurses do it


What is meant by aggressive oral care?

- Q shift (1 time a shift)- much more intensive in the ICU, especially w/ ventilator pts. Who have a large incidence of VAP- ventilator pneumonia and very frequent oral care is rec.

- Before the first meal of the day

- Brushing to remove plaque (bacteria is stored)

- Swabbing to remove debris and absorb secretions (use a toothette)

- Oral suction as needed (most common is for trach, use a tonsil tip suction device for oral secretions)

- Anti-bacterial, alcohol-free mouth rinse
Prescription rinse as needed (e.g. chlorhexedine)

- Mouth moisturizer (dry mouth is common)****

- Lots of things you can do for people who have dry mouth

- Typically caused by multiple meds.


Medications and FWP

***Medications are never given with water.
Pills are given in a spoonful of applesauce, pudding, yogurt or thickened liquid.

- Pills may need to be crushed to help the patient swallow the medication.

- If a patient receives an order for a liquid medication, the nurse should contact the MD or pharmacy and ask about a pill form of the medication.

- If the medication cannot be changed the dietary department can supply the appropriate thick liquid or a thickening agent to thicken the medication.


Education with FWP

- Really important to educate the family

- Family education emphasizes the rationale for allowing water intake and only water is permitted

-The SLP, dietitian, and nurse repeat the guidelines for water intake during the education process.

- Written material is provided to patients and families.

- Education is documented in the medical record.

- Families are generally cooperative and appear to understand the water protocol.

- The guidelines are very clear and easy to teach.

- The water protocol is thoroughly taught at each family teaching session with printed handout material provided.


Key to success for FWP

All staff are oriented to the water protocol to ensure consistency across disciplines and in any environment the patient and family may encounter while at Frazier.



- Frazier clinicians feel that quality of life has been improved for patients who have been permitted water.

- Patients frequently report their strong satisfaction with being allowed water to drink.

- The water protocol that is followed at Frazier may not be workable in all settings and with all patients, but there are variations that can be adapted according to environment and specific patient conditions and needs.


Variations On Other Water Protocols

- Patients need to be cognitively alert, able to sit, good oral.

- Use with outpatients, COPD watched carefully.

- Encourage fluids & push H2O, good oral care.

- No straws on free H2O. If cough on >50% of H2O trials then have H2O by spoon. Have used with some vent pts.

****variations compiled by Jan Lorman, PhD.

- Oral care critical for success.

- Eliminated all thick liquids. Insist on strict oral care. Use ice chips if marked coughing.

- Use antibacterial mouthwash in addition to oral care. ICU patients watched carefully. Improvement noted in pneumonia incidence, dehydration, cognition, speed of improvement. People much more compliant.

- Strict oral hygiene. Include medically stable patients- mainly in residential care. No negative outcomes thus far (started 2003).


Water protocol exclusions (15)

- Acute discomfort

- poor oral care

- non-compliant

- acute patients aspiration on other than thin liquids

- profuse aspiration

- severe respiratory conditions

- bedrest

- poor cognition

- no real pleasure from free water protocol

- medical fragility

- Very few excluded medically severe in ICU

- advanced PD & brainstem pts

- trach or vent pts with pulmonary disease hx

- history of aspiration pneumonia

- immune suppression


FWP implementation

- Assess the culture for staff’s level of understanding and appreciation of hydration and oral care needs of clients.

- Consider merging elements of oral care, FWP and hydration programs.

- Know your facility’s oral care protocol

- Do you need to initiate a protocol?

- Un-teach the aspiration pneumonia myth

- Share the literature

- Identify champions (nurses)

- Be the catalyst for change


Questions to consider in the assessment of dehydration risk factors: (copeman)

- Are sufficient drinks offered thru the day?

- Is a choice of drinks offered?

- Are the drinks served at the correct temp?

- Are the drinks placed within reach?

- Are appropriate drinking vessels used?

- Is adequate encouragement given to individuals?

- Are individuals suitably positioned to enable them to drink?

- Does anyone check that the drink has been consumed?

- Are additional drinks available upon request?

- Can individuals make their own drinks?

- Are suitable toileting arrangements in place?

- Can staff recognize signs of dehydration?

- Are sufficient staff available to serve drinks?


Be pro-active in oral hygiene care

1. Include all NSG staff in training

- RNs, LPNs, CNAs

2. TEACH the connection b/w

- oral hygiene & aspiration pneumonia

3. TEACH the oral care protocol

4. TEACH the water protocol

- Work with/train family



- Critical to success

- Frequent direct interactions with patient

- Most often responsible for personal care

- Challenges

- High turn over

- Time

- Commitment

- Direct training

--- Do not omit anatomy & descriptive function of swallow

--- Provide visuals: pictures of mouth, MBS videos, FEES

- Provide pictures/props of ‘dirty mouth’

- Provide personal perspective, i.e., would you want your grandmother to be treated this way?

- Pretest-Posttest method: cues them to what is important


Keys to success in implementing Programs of Hydration

- Commitment from nursing leadership

- Comprehensive assessment skills of licensed staff

- Education: Integrating commitment with skills

- Creative strategies thru brainstorming


Share evidence including

- Causes of aspiration pneumonia

- CDC recommendations (very specific about taking care of pts. Needs)

- Impact of oral care on incidence of HAP (hospital acquired pneumonia) and associated cost reduction

- Overuse and cost of thick liquids

- CMS (center for medicare and medicad services) LTC surveyor regulations (very specific about over modifying diets)

- Dehydration incidence, mortality, costs, & solutions


Aspiration Pneumonia Risk

- “Dysphagia and aspiration are necessary but not sufficient conditions for development of pneumonia.”

- Aspiration must be present, but will result in pneumonia only if the aspirated material is pathogenic to the lungs and host resistance to the aspirated material is compromised


********* Strongest Predictors of Aspiration 1 Pneumonia**********

Know this***

- Dependence for feeding (41%)*

- Dependence for oral care (40%)*

- Number of decayed teeth (34%)*

- Tube feeding (27%)*

- More than one medical diagnosis* (comorbidity)

- Number of medications prescribed

- Now Smoking*

- Underlying conditions that lead to pneumonia- immuno-compromised and poor oral care

- When people need to be fed, they don’t have any control, they may be fed when they are not alert


********* Strongest Predictors of Aspiration 2 Pneumonia**********

Know this***

- Reduced activity level (43%)*

- GER (28%)

- Esophageal dysmotility*

- Aspiration of food*

- Pharyngeal delay

- Low spillage point

- Excess residue

Significantly more subjects who developed aspiration pneumonia were bed bound (16%) and exhibited reduced activity levels (43%) as compared to those who did not acquire aspiration pneumonia.


Aspiration Pneumonia Risk Factors

The role of dysphagia/aspiration in the development of pneumonia may be better understood by considering the colonization of pathogenic bacteria and the host resistance to the process.


Bacterial Colonization of the Mouth

- The mouth harbors a host of microbes

--- Always found on the surfaces & in the nooks & crannies of the mouth

--- Soft tissues & teeth

--- Usually do us little harm as long as a person is health


Saliva & Colonization

- Reduced saliva = increased bacteria

- Bacteria attach to soft tissue and teeth

- Produce biofilm (pathogenic)

- Protects the bacteria against body’s defenses



Bacterial flora increase and are altered by severe underlying disease, malnutrition, inactivity, dehydration, xerostomia, over use of antibiotics and most importantly, dental and periodontal disease.


Why do some people who aspirate get pneumonia – and others don’t?

Depends on three factors:

1. Amount of bacteria aspirated (pathogen load)

1 mL (1 cm 3) 100,000,000,000 bacteria!

2. Strength of the aspirated bacteria (virulence)

Examples: Pseudomonas aeruginosa, Streptococcus mutans, Haemophilus influenzae

3. Condition of the immune system (health)
Institutionalized = Reduced resistance to pathogens



- involve the workers in the implementation of interventions to prevent health-care-associated pneumonia by using performance-improvement tools & techniques.

- Develop & implement a comprehensive oral-hygiene program


Nursing Home Standards of Care

- Nursing homes must give residents necessary assistance with bathing, dressing, eating and other personal needs.”

- Provide needed personal care services including bathing, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, and cleaning and cutting of fingernails and toenails



- thickening liquids has been and continues to be the most frequently used compensatory intervention in hospitals and LTCs.

- Nonetheless, there are little extant data that convincingly demonstrate that drinking thickened liquids has a significant positive effect on health outcomes such as pneumonia, hydration, nutrition or QOL.

- The frequency of aspiration pneumonia was not significantly different among patients who aspirated thin liquids and those who did not aspirate.

- Schmidt (1994) reported aspiration of thicker fluids and semi-solids was predictive of aspiration pneumonia and death.

- The risk of developing aspiration pneumonia was significantly greater if thick liquid or more solid consistencies were aspirated.

- Dehydration was more common with thick than thin liquids.

- More patients assigned to thick liquids than the chin down posture intervention had dehydration (6% vs 2%), and UTI (6% vs 3%).


Mortality Associated with Dehydration

- Dehydration is associated with significant mortality.

- Rates of 46 to 48% have been reported.

- People hospitalized with dehydration should be considered at increased risk for dying within the year following admission (Warren, 1994).



- Xerostomia (dry mouth) which can significantly and negatively impact nutrient intake, reportedly affects more than 70% of the geriatric population

- A low fluid intake may influence the amount of food eaten.

- Elderly individuals may be eating inadequately because not enough
fluids are being given.

- Malnourishment and dehydration go hand in hand.

- Dysphagic stroke patients receiving thickened liquids failed to meet fluid intake requirements.


Dehydration can lead to a variety of negative health consequences including:

- changes in drug effects

- infections

- poor wound healing

- pressure sores

- decreased urine volume

- urinary tract infections

- lethargy

- constipation

- altered cardiac function

- acute renal failure

- weakness, falls due to hypotension

- declining nutritional intake

- Water intake of nursing home residents in a 24 hour period was inadequate in 91 of 99 cases.

- dehydration is ranked one of the ten most frequent admitting dx in a study of Medicare hospitalizations.


The health care expense associated with dehydration is enormous

- The potential for reduction in health care spending related to avoidable hospitalizations in dehydrated patients could have been as much as 1.14 billion dollars in 1999.

- “Dehydration costs Medicare $450 million dollars monthly.”

- Strategies to maintain hydration should
include practical approaches to induce
the elderly to drink enough fluids.


Dehydration Prevention:

- frequent encouragement to drink

- assisting the person with drinking

- offering a wide variety of beverages

- advising to drink often rather than
large amounts and

- adaptation of the environment and
medications as necessary.