FWP Flashcards
History of FWP
Frazier Rehab’s water protocol was implemented in 1984 as a response to non-compliant patients who were covertly consuming thin liquids or refusing to drink thickened liquids.
- The key is to listen to your patients
- Thickened liquids became the key without an evidence, but pts. started cheating (and we told them they would get pneumonia)
- Pts. didn’t believe SLPs knew what they were talking about in regards to thickened liquids, so they were noncompliant
- In 1984 many of our patients refused to believe they were going to get pneumonia.
- As we observed that many did not, we felt the need to alter our approach to strict dysphagia intervention.
- Non-compliant patients were not developing aspiration pneumonia despite evidence of aspiration on videofluoroscopy.
Basis of the FWP
- FWP allows thin liquid aspirators to drink water.
- Anytime during the day as long as it is not during meals or 30 mins after a meal
- compromise to thick liquids
False belief about aspiration
all aspirating patients were at risk of developing aspiration pneumonia was held.
Who created the FWP
The Frazier Water Protocol was developed through the inter-disciplinary cooperation of physicians, speech-language pathologists and a dietitian.
Dr. Judah Skolnick
- Pulmonologist
- Stated that water was safe because:
1. The body is approximately 60% water.
2. Tap water is a near neutral pH and so is compatible with other body fluids.
3. Tap water will not cause a chemical injury as might be expected with liquids such as soda, tea, or coffee.
4. If a drink of water is aspirated it will be absorbed by the lung mucosal tissue without harm.
5. Unlike an aspirated green bean or bite of chicken, water does not obstruct the airway. (water will travel through)
Water
- Up to 60% of human body = water
- 70% of brain = water
- 90% of lungs = water
- WATER ONLY! Not other liquids
- A volume of 25 ml of highly acidic contents carries more risk than pH neutral fluids of the same volume. (Schwartz, 1980)
- Most municipal tap water is a nearly neutral pH and very close to the pH of bodily fluids (pH = 7.2).
- Therefore, the presence of water in the pulmonary system should not cause a chemical injury to the mucosa of the lungs
Absorption of fluid in the lungs
- The ability of the lung to rapidly absorb water is well known.
- Aquaporins are water conducting channels in the lung endothelium and epithelium. (in all organ tissues)
- Water aspirated during fresh water swimming or drinking is rapidly absorbed from the airspaces
Why is there scant evidence of the safety of allowing thin liquid aspirators to drink water?
- Hindsight is 20-20
- 2000-3000 subjects needed to empirically prove safety of water (difficult and costly)
- Funding limitations
Evidence based research water protocols: Garon
•20 stroke patients known to aspirate thin liquids
- None of the patients in the control group reported satisfaction with thickened liquids and all reported a desire for water or ice chips to quench thirst. Garon et al. found patients who were allowed water expressed a high degree of satisfaction and reported thickened liquids did not quench thirst.
- Nobody got pneumonia, dehydration or other complications
•Free-water subjects reached “no aspiration” status faster (33 days) than control subjects (39 days) [no statistical comparison of this variable]
Evidence based research water protocols: Bronson-Lowe
Conclusion: In this study, the FWP did not exacerbate the risk of pneumonia.
Evidence based research water protocols:
Becker
Explored impact of water protocols on adverse event rates; recovery trajectories and length-of-stay. 15 participants and 11 controls.
- Participants were confirmed aspirators on liquid in VFSS
- Mean hospitalization dramatically shorter in water protocol patients.
Evidence based research water protocols:
Carlaw
16 participants enrolled (7 controls- delayed implementation group)
- All participants had confirmed dysphagia for thin liquids on VFSS at baseline (13 were penetrators or aspirators)
- 6 of the controls subsequently crossed-over to water protocols
- No adverse events (pneumonia; acute-care hospitalizations) experienced by any participants.
Evidence Base for Water Protocols- GF Strong
GF Strong has developed a “supervised protocol” for those unable to take water independently.
Exclusion: active PNA (pnuemonia); absent swallow reflex; uncomfortable cough.
Conclusion: Results of this trial to-date suggest that the GF Strong water protocol can be safely implemented in rehabilitation settings, with positive outcomes in hydration and quality-of-life.
*** in the early days of dysphagia, quality of life was not considered
Evidence based research water protocols:
Frey
The results support the safe intake of water by persons with CVA and dysphagia admitted to acute neurorehabilitation who are restricted to thickened liquids.
Evidence based research water protocols:
Karagiannis
- The adverse effects developed in patients with severe neurodegenerative disease.
- These patients were bedridden and dependent for feeding or were limited in mobility.
- Researchers recommended water not be permitted to acute patients, patients with severe neuro conditions, and immobility.
QOL was improved for patients allowed water as compared to the controls. - Recommend subacute patients with relatively good mobility should have choice after being well-informed of the relative risk.
- Current findings do not obviate the need to deviate from the FWP.
Cochrane Review
Allowing children who have thin fluid aspiration to drink water may assist in providing enough fluid without endangering the lung.”
- Aspiration Pneumonia Incidence Study at Frazier
2. Dehydration Incidence
- Two of the 234 patients developed aspiration pneumonia (.9%). Both were suspected of aspirating solid foods.
- In the same chart reviews of 234 inpatients, we found five cases of dehydration severe enough to require IV fluids.
Frazier Water Protocol Methods
- Thickened liquids are recommended and provided, but water is permitted between meals.
- Between meals only, because if you were to aspirate the water while eating a meal, the food could be aspirated with it and then the pt. would have a chance of getting pneumonia
- Compensation techniques are also used with water, because aspirating is not pleasant and pts. are not good about at keeping the techniques up
- Interventions to minimize aspiration of water as well as thickened liquids and foods are provided therapeutically.
- Compensatory maneuvers and behaviors are taught to patients, families and staff as is deemed appropriate for each patient.
Informed recommendations
The clinician should be sure that the water source is safe.
- If the water is not safe, use bottled water
- Clinicians who decide to pursue allowing dysphagic patients to drink water should be aware of the risks and benefits, and be prepared to make informed recommendations.
- The dysphagia clinician should also make an independent consideration of the patient population served.
—You have to think about the patients, think about quality of life, what are their disorders?
— There is a very high correlation between tube feeding and aspiration
Informed Recommendations- for acute care pts.
- Water is recommended for acute care patients on a case-by-case basis and require physician orders for the initiation of water intake.
- The order is written as “Frazier Water Protocol”.
- Ice chips are more likely the first step toward allowing water in our acute care setting.
Frazier Water Protocol Guidelines
The guidelines have been tailored to meet the needs of the patients served in this rehab facility. At Frazier, all dysphagic patients are allowed water. An order is required to NOT allow water.
- All patients referred to speech-language pathology are screened with water on the initial bedside visit to the patient.
- Even if the pt. is not coming in with signs of dysphagia
- Instrumental swallow exams to determine pathophysiology of dysphagia are conducted on nearly all dysphagic patients referred to speech-language pathology.
- Results of the exams contribute to treatment planning for dysphagic intervention.
Frazier Water Protocol Guidelines
- The purpose of the screening (3)
- to determine if patients are demonstrating signs and symptoms of dysphagia;
- to check for level of alertness and presence of impulsivity;
- and to decide if further dysphagia evaluation is warranted.
The SLPs conduct dysphagia therapy per intervention approaches that include:
- Intervention as usual***
1. sensory behavioral techniques
2. motor behavioral techniques
3. postural compensations
4. facilitating maneuvers - Sensory – sensory awareness thru pressure, temp stimulation as well as bolus size and texture manipulation