ACQ Vol 11 No 1 2009

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36 Sp eech Pathology Australia
MULTICULTURALISM AND DYSPHAGIA
Keywords:
dysphagia,
free water,
aspiration pneumonia,
dehydration
The most common reason for prescribing thickened fluids
to dysphagic patients is to avoid respiratory infections
and pneumonia as a result of aspirating thin liquids. Most
clinicians working with dysphagic patients recognise that
compliance with recommendations for thickened fluids can
be challenging, particularly in patients with cognitive impair­
ments who may not understand why speech pathologists
prescribe thickened fluids. Because of this, there has been
considerable interest in “free water protocols” in recent years
in Australia and overseas. These protocols advocate access to
water rather than thickened fluids, provided certain strict
conditions are met. The most well-known protocol is the
Frazier Free Water Protocol, which is summarised in table 1.
In 2005, via the Dysphagia listserv .
com/), Janis Lorman, an American speech-language
pathologist invited facilities that were using a free water
protocol to complete a survey. There were 19 respondents: all
indicated that the protocol was working and that there was
no greater incidence of pneumonia. Full details of the survey
are presented in table 2.
To increase our understanding of why free water protocols
have received so much interest, it is important to understand
the factors that have led to the development of these protocols.
These include the risk of dehydration in patients on thickened
fluids, as well as risk factors associated with aspiration
pneumonia, such as colonisation by bacteria.
Dehydration
To be well hydrated, an average adult male requires 2.9 litres
of fluid per day, whereas an average adult female requires 2.2
litres (Kleiner, 1999). Poor compliance with thickened fluid
recommendations may be associated with an increased risk of
patients becoming dehydrated. Studies into the fluid intake of
stroke patients have found a negative impact of prescription
of thickened fluids such as a need for supplementary fluids
(Whelan, 2001), and failure to meet daily fluid requirements
Free W ater Protocols
A review of the evidence
Claire Langdon
For many years in dysphagia management thickened
fluids have been prescribed to patients who aspirate thin
liquids. In the United States, certain facilities have
allowed access to water for aspirating patients without an
increase in adverse events. There is much interest in
these “Free Water” protocols, which reportedly result in
increased patient satisfaction and reduced dehydration.
This article reviews aspiration pneumonia and factors
that may contribute to development of respiratory
infections. Free water protocols may be a useful alter­
native for patients with good oral care and minimal co-
morbidities, though there is a need for further research to
explore this.
for patients on thickened fluids (Finestone, Foley, Woodbury,
& Greene-Finestone, 2001). A recent randomised controlled
trial (RCT) found that dehydration was more prevalent in
subjects assigned to thickened fluids as opposed to postural
strategies, and that the 3-month cumulative incidence of
pneumonia in known aspirators was lower than expected
(Robbins et al., 2008). Dehydration levels of as little as 1%
may adversely impact on cognitive performance (Lieberman,
2007). It is therefore interesting to note in the free water
protocol survey (table 2) that several facilities reported
improved hydration/decreased dehydration and improved
cognition as a result of access to water.
Aspiration pneumonia
The body’s defence systems
The first line of respiratory defence comes from barriers such
as mucous and cilia (Boyton & Openshaw, 2002). Respiratory
defences against solid particles include alveolar macrophages,
while the lymphatic system copes with fluids (Curtis &
Langmore, 1997). The immune response includes lactoferrin,
lysozyme, collectins and defensins (Boyton & Openshaw,
2002). Cell surface fibronectin has been shown to prevent the
adherence of gram-negative rods to receptors on oropharyngeal
cells in normal hosts (Cassiere, 1998). However, in patients
with underlying illness, cell surface fibronectin is cleaved off,
leaving receptors to gram-negative rods exposed (Cassiere,
1998; Woods, 1987). Although many challenges are dealt with
by the immune system, concentrated pathogens or a weakened
immune system can mean that respiratory tract infections
develop (Boyton & Openshaw, 2002; Cassiere, 1998; Duits et
al., 2003; Finucane, Christmas, & Travis, 1999; Kikawada,
Iwamoto, & Takasaki, 2005; Nicod, 1999). Patients with
underlying respiratory disease such as chronic obstructive
pulmonary disease (COPD) are not as likely to be able to clear
aspirated pathogens; in fact, there is speculation that patients
with COPD are chronically colonised by bacteria, with exacer­
bations occurring when the balance between the immune
system and bacterial overgrowth is altered (Wilson, 1998).
Smoking suppresses ciliary action (Terpenning, 2001) and
impairs mucociliary clearance, the chief defence mechanism
for solid particles (Crystal, West, Barnes, Cherniak & Weibel,
1991). Stroke patients with impaired cough reflex have been
found to be at greater risk of aspiration pneumonia (Adding­
ton, Stephens, Gilliland, & Rodriguez, 1999; Addington,
Stephens, & Gilliland, 1999).
Colonisation by bacteria
In the model proposed by Langmore et al. (1998) colonisation
of the oropharynx by bacteria is the first step in a sequence
that may lead to the development of pneumonia. The oral
cavity is colonised by more than 400 species of aerobic and
anaerobic bacteria (Brook, 2003). Most aspiration pneumonia
is bacterial in origin (Millns, Gosney, Jack, Martin, & Wright,
2003). Reduction in salivary flow and poor oral clearance of
bacteria are potentially the first steps that lead from oro­
pharyngeal colonisation to pneumonia (Palmer, Albulak,
Fields, Filkin, Simon & Smaldone, 2001). Langmore et al.