Free Water Protocol: Free for who?
For decades, the Free Water Protocol (FWP) has been a hot topic in dysphagia management. It allows patients with thin liquid dysphagia to drink regular, thin liquid water between meals (even if they have to thicken other liquids). But is it safe and effective? At the surface level it would seem so, but it’s definitely not for everyone. Let’s dive deeper into the pros and cons for a better view.
The Pros
Improved Quality of Life: Many patients find thickened liquids… unpleasant. Have you tried them? If not, give it a go. FWP allows people to enjoy the taste and sensation of crisp, cold, refreshing water, often removed from the diet completely when a patient is NPO. Remember, we are mostly water. If you weighed 150 pounds, 90 pounds of you would be water. Craving water is as natural as it gets.
Increased Hydration: Ready to get hit with some crazy logic? If you don't like the beverages you're given to drink, you won't consume enough of them. When you don't drink enough, you become dehydrated. It's true, look it up. FWP allows patients to enjoy liquid again, potentially increasing fluid intake and maintaining adequate hydration.
Improve Oral Hygiene: Oral and pulmonary infection risk starts in the saliva. Picture the saliva in your mouth as a freely flowing stream. When working properly, that stream runs clear and uninhibited from the mouth to the throat, where it can be swallowed down into the esophagus and stomach. The bacteria in this stream don't cause us any trouble because it's continuously moving out of the oral cavity, away from the airway, and into the stomach's acidic environment—frequent sips of water help to facilitate this process.
Without regular access to water, our oropharynx acts like a stream, but in a drought. Eventually, it can become devoid of moisture, and your saliva and secretions become solid and crusty, like the dirt and rocks at the bottom of the stream. Bacteria get stuck in this dry wasteland and begin proliferating, eventually spreading into the airways and bloodstream.
The Cons
Aspiration Risk: Thin liquids are more easily aspirated than thickened liquids. FWP may increase the risk of aspiration, especially for patients with severe dysphagia. However, the other side of this coin is that thickened liquids, when aspirated, are more harmful to the lungs.
Limited Evidence: Despite its long history, research on FWP is limited and often shows mixed results. Its effectiveness in preventing aspiration pneumonia is still debated.
Patient Selection: A screwdriver is no good as a hammer. Similarly, FWP is a tool that can't be used by everyone. If we treat it like a panacea, problems will pop up. Careful selection is crucial, considering cognitive status, mobility, and underlying medical conditions.
What does the available evidence tell us?
A 2017 systematic review examined eight studies on the Free Water Protocol. While systematic reviews are typically the highest evidence, this study was unfortunately deemed low quality due to the small number of participants and varying study designs. However, the review concluded that the FWP was safe for carefully selected patients. Who are those patients?
Those who are:
Mobile (able to get out of bed and move about)
Without neurodegenerative diagnoses
With either intact cognition or adequate supervision
These patients did not develop pneumonia with the FWP. Good news, right? Not so fast. A couple of years later, in 2019, another study looked at 104 patients with stroke or traumatic injury. No positive outcomes of FWP were found. And a small number of patients developed pneumonia and were excluded from the study (Even though the numbers were not statistically significant, it's still concerning). This inconsistency highlights the need for more research, especially with medically complex patients or those with higher medical acuity.
Clinical Considerations
How can we use the benefits of FWP and minimize the drawbacks?
Know Your Patient: Conduct a thorough and comprehensive swallow evaluation with an instrumental study to assess the patient's strengths, weaknesses, and potential strategies for overcoming those weaknesses. Then, determine if FWP even needs to be considered.
Individualize The Approach: FWP should be tailored to each patient's needs and preferences. No, not everyone is appropriate, but let's not throw out the whole album just because of one bad song. Are they craving water and willing to accept the limited research available for FWP? Is the patient mobile, without a neurodegenerative diagnosis, and with intact cognition? Can we get them up and moving as much as possible if they are immobile? If they're confused, can we provide adequate supervision? Discussing these questions with the interdisciplinary team is a good starting point for determining if FWP is right for your patient.
Monitor Closely: Once on FWP, patients must be kept on caseload for ongoing education, assessment, and guidance. Putting a patient on FWP is just the beginning. You wouldn't walk out of the theater after watching the coming attractions, would you? Follow your patient closely and monitor for signs of pulmonary infection so we can adjust the plan of care as soon as possible.
The Bottom Line
FWP can be a valuable tool in dysphagia management, but it's not a magic bullet. It's crucial to weigh the potential benefits and risks carefully and make informed decisions based on the latest research and the patient's individual needs.
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