Vol. 16 •Issue 24 • Page 6
Frazier Water Protocol
Promote free water, good oral hygiene
While it's a commonly held belief that aspiration of water is harmful, it is untrue. The Frazier Water Protocol (FWP) allows people with dysphagia free access to water with almost no incidence of aspiration pneumonia.
"Aspiration of water is a benign event; we've known that for quite some time," said Tom Franceschini, MS, CCC-SLP, coordinator of speech pathology and swallowing disorders at Hancock Regional Hospital in Greenfield, IN. "Over the years therapists have picked up on the idea that if a drop of water enters the lungs, the patient will die. We're not sure where that came from."
Unlike soda or coffee, water has a neutral pH level. Therefore, it is well tolerated by the lungs and is quickly absorbed into the bloodstream. Kathy Panther, MS, CCC-SLP, inpatient rehabilitation director at the Frazer Rehab Institute, in Louisville, KY, developed the Frazier Water Protocol 22 years ago.
Prior to its development, the speech-language pathologist's main concern was preventing aspiration pneumonia. The focus now has now shifted to preventing dehydration.
"Dehydration is probably one of the most misunderstood conditions by health care providers and the general public," Panther told ADVANCE. "The nutrition literature says that a large segment of the population is at least mildly dehydrated."
At one time, dehydration was not even part of the vocabulary in speech-language pathology. The fact that the Frazier Water Protocol combats dehydration was an unexpected side effect, she said.
Negative consequences of dehydration include changes in drug potency, trouble with healing from infections and wounds, urinary tract infections, constipation, confusion, lethargy, acute renal failure, and a malfunctioning cardiac system.
The aging process also plays a part in dehydration because older adults have a diminished sense of thirst.
"Elderly in nursing homes are chronically dehydrated, which has to do with the fact that they don't have access to liquids a lot of time," said Franceschini.
Other factors that contribute to the difficulty of older adults obtaining water are losses in mobility, dexterity and visual acuity, as well as communication and cognitive impairments. Some patients may avoid water because they are embarrassed by the fact that they need assistance to use the bathroom.
The Frazier Water Protocol is simple. Its most important guideline is that individuals drink only thickened liquids with meals. Free water is permitted only between meals, and it can be taken up until the first bite of food. Typically, patients wait approximately 30 minutes after eating before drinking water again.
The half-hour time frame is arbitrary, Franceschini noted. "We used to wait 30 minutes, but we modified that rule because it didn't always work. Thirty minutes later you could still find scrambled eggs in somebody's cheek."
Now, the nurses perform a quick check of the oral cavity between meals to make sure no food particles are present.
"Hopefully, any residue that's left behind has been swallowed in the subsequent amount of time," he said.
Medications are not to be taken with water, as pills may be washed into the lungs.
The guidelines also suggest that the patient be offered water throughout the day. A wristband or a picture of a water droplet on a pitcher of water or the patient's door, for instance, indicates to other staff members that an individual is on the protocol.
By having patients wear an identifying wristband as they travel throughout the building, "everybody realizes that the person is on the Frazier and they're allowed to offer them water," said Franceschini. "That's one of the key components-not just that they get water, but that they're offered water on a frequent basis."
Staff education is crucial when implementing the protocol. The Hancock Speech Department initially modified the guidelines so all staff could understand the protocol and then developed a letter for families and caregivers to increase their understanding of the protocol as well.
Patients are encouraged to use swallowing compensatory strategies when drinking water. For example, if someone takes water by teaspoon amount with a chin tuck, that information is written on the wristband by the speech-language pathologist. There also may be a sign over the patient's bed displaying the rules of the protocol.
Speech-language pathologists can offer patients water during therapy sessions and monitor progress or decline by measuring the frequency of the cough, if present. "It's a good gauge to use to advance the patient," said Panther.
The success of the protocol calls into question the use of thickened liquids. She said they are unpalatable and patients are unlikely to consume enough to meet hydration needs.
"We were deluding ourselves to think our patients were really following our recommendations about thickened liquids," she said. "The compliance literature shows that with health related recommendations if you can't see immediate results, you're less likely to comply. The need for water is very primitive. When it is not permitted, people may not stick to the plan very well."
The most significant aspect of the protocol is its ability to significantly decrease the incidence of pneumonia to the point that it is rarely seen. After the speech-language pathologist performs a modified barium swallow (MBS) or bedside exam, the clinician continues to monitor the patient for signs of aspiration, high temperature, positive chest X-rays and elevated white blood cell count.
These events usually don't occur, Franceschini stated. "If anything, we see patients who are happier and willing to take their thickened liquids. Once they are well hydrated, there is no problem."
Of the five leading causes of aspiration pneumonia, dysphagia alone is not one of them, reported Susan Langmore, PhD, CCC-SLP, associate professor and director of swallowing rehabilitation in the Department of Otolaryngology-Head and Neck Surgery at the University of California, San Francisco.
She conducted the Geriatric Oral Science Project (GOSP), which identified the five leading causes: dependent feeding, dependent oral hygiene, missing teeth, multiple medications and tube feeding.
Bolus size and feeding rate most likely are the problematic issues in dependent feeding, said Franceschini. "You're not in control. Therefore, your swallow isn't as functional, and you could choke. I try to get in quick and teach patients who have had a stroke to start using their unaffected side. We used to wait; now patients learn to eat left-handed."
In the area of oral hygiene, many patients aren't even getting their mouths cleaned on a daily basis, he said. "Patients on ventilators or those who are NPO never brush their teeth. Within days, the bacterial growth is amazing."
Implementing a good oral hygiene care program is crucial in dysphagia management because patients who have dental disease and exhibit poor oral care are more likely to develop aspiration pneumonia, regardless of whether they are dependent on others.
"The mouth is full of bacteria," said Franceschini. "It is colonized very quickly with gram-negative bacillus, staphylococcus aureus, or yeast, which are then micro-aspirated or aspirated with other things into the lungs. Sometimes there's so much bacteria and it's so virulent that they overwhelm an already impaired host defense system. That's where the aspiration pneumonia develops."
Aspiration of tap water is a safe event for those with good oral hygiene. Good oral hygiene programs, which many speech-language pathologists have added to the Frazier Water Protocol over the years, begin with a good oral assessment.
"Somebody needs to look in the patient's mouth once or twice a day for signs of bacterial infection, candidiasis, poor oral hygiene, particles of food, or dry mouth, which can be very dangerous because bacteria like that kind of environment," said Franceschini.
Good oral care requires brushing all areas of the mouth-including the tongue, palate, cheeks and sulcus-to make sure the bacterial colonies are disrupted and cleaned away.
Adequate hydration also must be maintained.
"Dehydration leads to lethargy," he said. "The more lethargic patients become, the more dependent they become in their feeding. What's the No. 1 cause of aspiration pneumonia? Dependency for feeding. The whole thing is cyclic."
Well-hydrated patients have stronger immunity. "You can do so much with a little oral care. Well-hydrated patients are happy, won't refuse therapies, are comfortable, and will eat better."
1. Armstrong-Esther, C.A., Browne, K.D., Armstrong-Esther, D.C., Sander L. (1996). The institutionalized elderly: Dry to the bone! International Journal of Nursing Studies, 33 (6): 619-28.
2. DiPippo, K.L., Holas, M.A., Reding, M.J. (1992). Validation of the 3 oz. water swallow test for aspiration following a stroke. Archives of Neurology, 49: 1259-61.
3. Feinberg, M.J., Kneb, J., Tully, J., Degall, L. (1990). Aspiration and the elderly. Dysphagia, 5: 61-71.
4. Feinberg, M.J., Knebl, J., Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over three years. Dysphagia, 11: 104-09.
5. Garon, B.R., Engle, M., Ormiston, C. (1997). A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation, 11 (3): 139-48.
6. Gaspar, P.M. (1999). Water intake of nursing home residents. Journal of Gerontological Nursing, 25: 23-29.
7. Gross, C.R., Lindquist, R.D., Wooley, R.G., et al. (1992). Clinical indicators of dehydration severity in elderly patients. The Journal of Emergency Medicine, 10: 267-74.
8. Holas, M.A., DePippo, K.L., Reding, M.S. (1994). Aspiration and relative risk of medical complications following stroke. Archives of Neurology, 51: 1051-53.
9. Hoffman, N.B. (1991). Dehydration in the elderly: Insidious and manageable. Geriatrics, 46 (6): 35-38.
10. Kleiner, S.M. (1999). Water: An essential but overlooked nutrient. Journal of American Dietetic Association, 99 (2): 200-06.
11. Langmore, S.E., Terpenning, M.S., Schork, A., et al. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13: 69-81.
12. Loeb, M.B., et al. (2003). Interventions to prevent aspiration pneumonia in older adults: A systematic review. Journal of American Geriatric Society, 51: 1018-22.
13. Millns, B., et al. (2003). Acute stroke predisposes to oral gram-negative Bacilli: A cause of aspiration pneumonia? Gerontology, 49: 173-76.
14. Palmer, L.B., et al. (2001). Oral clearance and pathogenic oropharyngeal colonization in the elderly. American Journal of Respiratory Critical Care Medicine, 164 (3): 464-68.
15. Scannapieco, F.A., Mylotte, J.M. (1996). Relationships between periodontal disease and bacterial pneumonia. Journal of Periodontal Research, 67 (10): 1114-22.
16. Schmidt, J., Holas, M., Halvorson, K., Reding, M. (1994). Videoflouroscopic evidence of aspiration predicts pneumonia and death, but not dehydration following stroke. Dysphagia, 9: 7-11.
17. Seymour, D.G., Henschke, P.J., Cape, D.T., Campbell, A.J. (1980). Acute confusional states and dementia in the elderly: The role of dehydration/volume depletion, physical illness and age. Age and Aging, 9: 137-46.
18. Shay, K. (2003). Infectious complications of dental and periodontal disease in the elderly population. Clinical Infectious Diseases. 37 (6): 860.
19. Yoneyama T., Yoshida, M., Ohrui, T., et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of American Geriatrics Society, 50: 430-33.
For More Information
Tom Franceschini, (317) 468-4660, e-mail: firstname.lastname@example.org
Kathy Panther, (502) 582-7475, e-mail: email@example.com
Jason Mosheim is an Assistant Editor at ADVANCE. He can be reached at firstname.lastname@example.org. Additonal resources for this article are available in the online version of the story at www.advanceweb.com/speech.
FWP: A Brief History
In the early 1980s Kathy Panther, MS, CCC-SLP, inpatient rehab director of the Frazer Rehab Institute, in Louisville, KY, was practicing what she considered conventional dysphagia management.
"I provided only thickened liquids and no thin liquids for those who were known to aspirate them," she said.
She soon discovered that the patients were being non-compliant. Some even were divulging that they were eating and drinking whatever they wanted, despite the fact that they were known to aspirate thin liquids. Yet, they were not getting pneumonia.
"We had this correlation in our heads that if you aspirate, you get pneumonia. We began to question why they weren't getting pneumonia because that really was a common view of dysphagia practitioners at the time," she recalled.
Working closely with Judah Skolnick, MD, a pulmonologist in the Louisville, KY, area, Panther asked him if he could explain why this was happening.
"He basically corrected us," she said. "He said, 'Why don't you let them have water? Water is not going to cause damage to their lungs.' Of course, we were aghast. Water was a thin liquid; and if they were going to aspirate thin liquids, they certainly were going to aspirate water, too."
Dr. Skolnick explained the rationale. Because water had a neutral pH, it would not cause a chemical injury. Water would be absorbed into the blood stream without complications. It wouldn't obstruct the airway like a solid piece of food.
Panther went on to develop the Frazier Water Protocol. Despite a very low incidence of pneumonia and improved quality of life, the protocol remains a controversial treatment modality because a large randomized controlled study has never been conducted.
"A lot of speech-language pathologists have been very hesitant to try it with their patients because they don't trust the fact that there isn't a great deal of research on it," she said. "We just began trying it with our patients, and we had great results. They told us they were very satisfied and that their thirst was quenched."
There was no increase in pneumonia either.
"We have a very low pneumonia rate," Panther said. "We hardly ever see it."
Once she got further into using the protocol, "we didn't want to withhold it from our patients when we knew it to be a good thing," she said.
Furthermore, the discovery of the aquaporin channels in the lungs as being the mechanism for water absorption has eased some minds. The discovery was made by pulmonary physiologist Richard Effros, MD, of the Pulmonary and Critical Care Department at the Medical College of Wisconsin in Milwaukee.
"That was really big," Panther said. "The aquaporins act like a sieve. When water enters the alveoli [in the lungs], it is taken up into the blood vessels and carried out to the bloodstream very rapidly. That explains the absorption and has made people feel pretty good about this."
She continues to receive e-mails and phone calls on a daily basis from individuals all over the world who are putting the protocol into place-not just in rehab hospitals, but also in long-term care, acute care and home care settings.
"People are realizing that thickened liquids are not the end-all, be-all anymore. They're realizing that tube feedings don't protect you in every case either," she said. "Not everybody is going to buy this, but more people have recognized that we need to be thinking about the quality of life and balancing that with good hydration and good protection of the airway."