ACQ Vol 11 No 1 2009

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ACQuiring knowledge in sp eech, language and hearing, Volume 11, Number 1 2009 37
MULTICULTURALISM AND DYSPHAGIA
decayed teeth in subjects with aspiration pneumonia, with
significantly more patients who reported they occasionally or
never brushed their teeth proceeding to develop aspiration
pneumonia. In a study that looked at 50 subjects who developed
aspiration pneumonia from a population of 358 veterans,
Terpenning et al. (2001) found the presence of Porphyromonus
gingivalis, Streptococcus sobrinus and Staphylococcus aureus
in saliva was significantly higher in subjects who developed
aspiration pneumonia, regardless of presence or absence of
dentition.
Professional oral care has been associated with a reduction
in aspiration pneumonia in nursing home patients (Abe,
Ishihara, & Okuda, 2001; Adachi, Ishihara, Abe, Okuda, &
Ishikawa, 2002). Elderly patients in residential care have high
oral yeast counts and oral candidiasis which are associated
with poor oral hygiene and neglect of care of dentures (Budtz-
Jorgensen, 1996). These factors are easily modifiable, and may
(1998) found that aspiration of secretions and excess secretions
in the mouth were both significantly associated with pneumonia
in dentate subjects. However, normal healthy adults commonly
aspirate saliva/secretions while sleeping, without any obvious
health effects (Cassiere, 1998; Gleeson &Maxwell, 1997).
Any condition that increases the volume or bacterial burden
of oropharyngeal secretions in a person with impaired defence
mechanisms may lead to aspiration pneumonia (Marik, 2001).
While normal saliva has 108 organisms/mL, periodontal disease
or poor oral hygiene may result in a higher concentration of
oral pathogens in the saliva, with saliva from a patient with
gingivitis (inflammation of the gums around the roots of the
teeth) containing up to 1011 organisms/mL (Mojon, 2002). In
the elderly debilitated patient, both salivary flow and swallowing
are frequently abnormal (Palmer et al., 2001).
Langmore et al. (1998) conducted a cohort study of male
veterans and reported a significant increase in the number of
Table 1. The Frazier Free Water Protocol
After several years of a conventional dysphagia program, Frazier’s swallowing management protocol changed
dramatically. Concern over patient and family non-compliance with thin liquid restrictions both within the facility and
after discharge led us to alter our protocol in 1984. Previously prohibited, oral intake of water became a major feature in
both treatment and day-to-day hydration. Features of Frazier’s program include the points listed below.
Safety of water
n The human body is about 60% water. Small amounts of water taken into the lung are quickly absorbed into the body pool.
n Unlike other liquids, water has a neutral pH. Water is free of bacteria and other contaminants and does not contain the
chemical compounds found in beverages. Aspiration of other liquids can lead to respiratory infections and pneumonia.
n Water provides a safe means of assessing patients with thin liquids. All patients (of any diagnosis) referred to speech
pathology are screened for dysphagia with water sips.
n Water is safely utilised in daily treatment of thin liquid restricted patients. Water therapy permits better recognition of
patient readiness for repeated videofluoroscopy and diet advancement.
Hydration
n Free water consumption is encouraged for all patients and makes a significant contribution in hydration for many.
n The risk and cost of IV fluids should be decreased.
n Post-discharge surveys of Frazier dysphagic patients indicate water often is the primary means of hydration.
Frazier Rehab Center’s water protocol – water between meals
n By policy, any patient NPO or on a dysphagic diet may have water.
n All patients are screened with water. Patients exhibiting impulsivity or excessive coughing and discomfort will be
restricted to water taken under supervision. Patients with extreme choking may not be permitted oral intake of water
due to the physical stress of coughing.
n For patients on oral diets, water is permitted between meals. Water intake is unrestricted prior to a meal and allowed 30
minutes after a meal. The period of time following the meal allows spontaneous swallows to clear pooled residues.
n After the screening described above, NPO patients are often permitted water.
n Patients who are thin liquid restricted wear blue bands to communicate the liquid restriction to all staff. Typically, the
band reads “No thin liquids except water between meals.” All staff are oriented to blue bands and check for bands
before offering liquids to patients.
n Water is freely offered to patients throughout the therapy day.
n Medications are never given with water. Pills are given in a spoonful of applesauce, pudding, yogurt, or thickened
liquid.
n Family education includes emphasis on the rationale for allowing water intake. The guidelines for water intake are
repeated by the speech pathologist, dietitian, and nurse during the education process.
Compliance
n Complaints of thirst were frequently voiced prior to 1984. Patients reported thickened liquids did not quench thirst.
n Water eliminates thirst and patient complaints are now much less frequent.
n Many patients and families object to thickened liquids. Since water is an option, patients appear more likely to comply
with the thin liquid restriction.
n Once home, preparation of thickened liquids often becomes burdensome. After days or weeks at home the family may
tire of patient complaints and abandon thickened liquids.
n Availability and cost of thickening agents and/or prepackaged thick liquids may preclude patient compliance.
n Thick liquid preparation in addition to other time and energy consuming patient care tasks can overwhelm families.
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