Use of Free Water Guidelines in Critical Illness Survivors With Dysphagia

Abstract

PURPOSE: The Frazier Water Protocol (FWP) is a part of dysphagia rehabilitation designed to allow patients whose diet restrictions include thickened liquids (nectar, honey or pudding consistency) to also have water and ice chips. Use of the FWP remains controversial due to the concern for pneumonia. There is limited information regarding use of the FWP for hospitalized patients with pulmonary diagnoses and the FWP is commonly discouraged due to risk of aspiration. The FWP used for this study was modified from its original version and was referred to as the free water guidelines (FWG). The purpose of this study was to evaluate the FWP in patients who are chronically critically ill in a respiratory care unit (RCU). METHODS: Inclusion criteria for this study were adult patients transferred to the RCU from an intensive care unit (ICU) that required thickened liquids after completion of a dysphagia evaluation. The FWG allowed for unlimited sips of water and ice chips between meals with oral cares 3-5 times daily. Repeat dysphagia evaluations were conducted at two week intervals. All 15 patients remained on the FWG until their diet was advanced to include thin liquids. The median length of hospital stay prior to the dysphagia evaluation was 28 days. A tracheostomy was present in 14/15 patients, 10 had nasoenteral tube (NT) and 5 had percutaneous tube (PT) as an alternative method for nutrition. Upon patient discharge from the RCU, 1 patient continued to require nutrition via a NT and 1 with P.T. RESULTS: During the study, 14/15 (93%) had advancement of diet away from thickened liquids, and 1/15 (7%) had diet regression during repeat dysphagia evaluations. One of fifteen (7%) patients was diagnosed with clinical pneumonia. CONCLUSIONS: Use of ice chips and water per the FWG for patients in this study showed a low incidence of aspiration pneumonia.