Effects of a Free Water Protocol on Inpatients in a Neuro-Rehabilitation Setting

Abstract

Background: Dysphagia is common among stroke and acquired brain injury (ABI) patients and may result in aspiration. To reduce the risk of thin liquid aspiration, patients are often restricted to thickened fluids. There is considerable clinical interest in the risks and benefits of offering oral water intake, in the form of water protocols, to patients with thin-liquid dysphagia. Objectives: A controlled pilot study of a free water protocol was undertaken at Riverview Health Centre, in Winnipeg, Manitoba to assess benefits, feasibility and possible complications of free water protocol. Methods: The study examined 16 individuals with stroke or ABI who were randomly assigned to either a control group on thickened fluids (six subjects) or a treatment group (ten subjects) that followed a free water protocol. The average length of time in the study was 4.3 weeks with a range of 1-17 weeks among all participants. Results: Throughout the study, there was no incidence of pneumonia in any of the sixteen participants. No statistically significant difference was noted in the weekly total liquid intake between the treatment group and the control group. Perceived swallowing related care results suggest statistically significant improvements from initial to final measures for both the treatment group (p = 0.004) and the control group (p = 0.02). However, a comparison of the change in both measures, between the treatment and control groups, shows no statistically significant differences. Conclusion: This pilot study suggests the need for larger scale work in order to more accurately identify the effects of free water protocols.

A systematic review and meta-analysis of pneumonia associated with thin liquid vs. thickened liquid intake in patients who aspirate

“…We performed a meta-analysis of the six RCTs 13,20–24 that examined the incidence of pneumonia in thin water protocols vs. thickened liquids (Figure 2, available online). Data from 135 patients were extracted from the six studies.…”

“…All seven studies were written in English. Five studies were published in full text; 13,14,[20][21][22] two were published in conference handouts. 23,24 One of the seven studies was a large, multicenter RCT, which compared the efficacy of postural adjustment and fluid modification in preventing dysphagia-related adverse events.…”

“…The other six studies compared the effectiveness of thin water protocols vs. thickened liquids for pneumonia prevention in patients in acute 21,24 subacute, 22 or rehabilitation hospitals. 13,20,23 Four studies examined patients with post-stroke dysphagia, 13,21,22,24 while the other two studies examined patients with various etiologies. 20,23 The six studies shared similar methodologies.…”

Implementation and Analysis of a Free Water Protocol in Acute Trauma and Stroke Patients

“…This result is consistent with previous research on the FWP in the rehabilitation setting. 1,[20][21][22][23][24][25] Participants in the experimental group showed a trend toward decreased days to discharge from the study, but the small number of participants that were followed precluded statistical testing.…”

“…19 To date, 7 studies of the FWP in the rehabilitation setting have been published. 1,[20][21][22][23][24][25] Of these, 6 did not reveal elevated rates of aspiration pneumonia in participants on free water protocols. One study, however, showed lung complications, including aspiration pneumonia, in 6 of 42 participants (14%) randomized to a group with access to water but no lung changes in the control group (n = 34).…”