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ACQ
uiring knowledge
in
sp eech
,
language and hearing
, Volume 11, Number 1 2009
43
MULTICULTURALISM AND DYSPHAGIA
however (Bulow, Olsson, & Ekberg, 2003). The Frazier Re
habilitation Centre in the USA decided to change the traditional
practice of prescribing thickened fluids to all patients with
dysphagia because of concern over patients’ non-compliance
with thickened fluids (Panther, 2003). From 1984, oral intake
of water by dysphagic patients has been permitted, following
a protocol typically labelled the Frazier Water Protocol (see
Langdon, this issue, table 1). It was argued that the aspiration
of water, a pH neutral substance, did no harm, and that the
benefits of allowing water outweighed risk associated with
aspirating it. Positive outcomes are reported (Panther, 2003),
but limited evidence supporting the use of free water
protocols has been published.
Garon, Engle and Ormiston (1997) investigated the out
comes for dysphagic stroke patients of allowing controlled access
to water versus thickened fluids. In a ran
domised control study of 20 in-patients with
known aspiration of thin fluids in a stroke
rehabilitation unit, no patient in either the
thickened fluid group or the group allowed
access to water developed pneumonia,
dehydration or complications. There was
no significant difference between the groups
in the time taken for the resolution of
aspiration of thin liquids, nor in total daily
fluid intake. Poor satisfaction with thickened
fluids was reported by 19 of the 20 patients.
The study has made a valuable contribution
to our knowledge, but is limited in its clinical application by
small subject numbers, strict exclusion criteria (including co-
morbidities that are common in the stroke population), and
employment of a rigid water protocol where participants had
to ask for water. It is, to date, the only published research
comparing these two management options.
To our knowledge only a few institutions in Australia are
currently implementing free water protocols in a formal,
deliberate way with explicit care pathways and systematic
collection of outcome data. Their project outcomes have been
presented at Speech Pathology Australia conferences (Carroll,
Ledger, Cocks, & Swift, 2007; Mills, 2008; Scott & Benjamin,
2007) but as yet are unpublished. The protocols used in these
studies are aligned with the Frazier Water Protocol with
reported minor modifications. Collectively, they have used
free water protocols across multiple clinical populations in
cluding stroke, neurosurgery, general medical, and dementia,
and in a variety of settings including acute, inpatient re
habilitation, community and residential care settings. None of
these studies, however, are randomised control trials with
control groups against which the health outcomes of their
patients can be directly compared. To our knowledge they
also did not routinely confirm the presence of aspiration of
thin fluids by objective assessment before introducing the free
water protocol to their patients.
Our research – plans and reality
At the Royal Adelaide Hospital (RAH) and its Hampstead
Rehabilitation Centre (HRC) campus in Adelaide, it was
decided in 2003 to instigate research on this topic. Imple
menting free water protocols would have significant implications
for both institutional and community dysphagia management,
with possible benefits in terms of increased compliance and
Keywords:
aspiration,
dysphagia,
free water protocol,
stroke
The background
In 2008, approximately 60,000 Australians
suffered a stroke (National Stroke Founda
tion, 2008). An estimated 37% to 78% of
patients will have dysphagia as a result of their stroke and
20% to 50% will aspirate (Martino et al., 2005). Traditionally,
the treating speech pathologist’s priority has been prevention
of aspiration, because of the relationship between aspiration
and development of pneumonia. Various studies have shown
that thickened fluids reduce the risk of aspiration (for
example, the Kuhlemeier, Palmer and Rosenberg (2001) study
of mild–moderately dysphagic patients) and so prescription
of thickened fluids has become the treatment of choice for
patients at risk of aspirating thin fluids.
In recent years, clinicians have become more cognizant of
pneumonia risk factors. The characteristics of the aspirate
(volume, pH, bacterial load), the individual’s health status
(including efficiency of pulmonary clearance, presence of
chronic obstructive pulmonary disease (COPD), and immune
status), and their oral hygiene are crucial in determining
whether a patient is at increased risk of developing pneumonia
(Langmore et al., 1998). In addition, the chance of developing
pneumonia or of dying is 9.2 times greater if a patient aspirates
thickened fluids or more solid substances as compared with
thin fluids (Schmidt, Holas, Halvorsen, & Reding, 1994). See
Langdon in this issue (p. 36) for a more detailed discussion of
pneumonia risk factors.
Clinicians have also become increasingly concerned about
the fluid intake and hydration of their patients on thickened
fluids. Although the fluid intake of patients consuming
thickened fluids may be inadequate (Finestone, Foley, Wood
bury, & Greene-Finestone, 2001; Patch, Mason, Curcio-Borg, &
Tapsell, 2003), opinion is divided as to whether this is a result
of being prescribed thickened fluids. It is hypothesised that
patients’ dislike of the taste and viscosity of thickened fluids
may result in a reduced intake (Finestone et al., 2001; Patch et
al., 2003). The alternative explanation, that the inadequate
fluid intake is the result of dysphagia, cannot be excluded,
F
ree
W
ater
P
rotocols
Collecting the evidence
Jo Murray and Anna Correll
Free water protocols are promoted as improving hydration,
without adverse consequences, in patients who aspirate
thin fluids. There is limited evidence for the relative
advantages of free water protocols versus traditional
thickened fluid management. A planned randomised
control trial is outlined, and the challenges it has pre
sented are discussed. We propose to continue the study
as a multi-centre randomised control trial. As clinicians,
we have found conducting research both rewarding and
challenging and would like to extend an invitation to
other stroke units to join us in our research efforts.
Jo Murray and Anna Correll
This article has been peer-reviewed