ACQ Vol 11 No 1 2009

MULTICULTURALISM AND DYSPHAGIA

F ree W ater P rotocols Collecting the evidence Jo Murray and Anna Correll

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

This article has been peer-reviewed

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.

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

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

Jo Murray and Anna Correll

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,

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

ACQ uiring knowledge in sp eech , language and hearing , Volume 11, Number 1 2009

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