On Free Water

In my previous post, I discussed the impact of thickened fluid prescriptions on quality of life and hydration. The hospital where I’m currently completing an entry-level placement has implemented a quasi-Free Water Protocol along the lines of the famous Frazier Water Protocol. The protocol was developed as the result of a series of underlying assumptions:

  • Water is safe
  • Water is good for you
  • Patients want water – they like it more and it’s easier for them to get.

Indeed, as is now well know, dysphagia is not a primary cause of aspiration pneumonia [1]. People aspirate all the time, and restricting their fluid intake will not stop them aspirating their secretions or reflux; which can transport oral colonies of bacteria to the lungs anyway.

The protocol is fairly straightforward:

  • Patients who are not impulsive, or do not cough excessively on water are permitted free access to water between meals (they recommend a 30min gap post-meal, but this is arbitrary).
  • Compensations (e.g. single-sips, with a teaspoon, postural compensations, etc.) are advised on a case-by-case basis.
  • Oral health is closely monitored, and oral hygiene is provided for patients unable to attend to it themselves.

free-clip-art-waterThe Evidence

  • An early study [2] found that access to free water did not significantly increase oral intake of fluids, but the group with access to free water reported much greater satisfaction with this option. None of the clients (10 controls, 10 in trial – all in the acute stage of stroke, with strict inclusion criteria) experienced dehydration or pneumonia. The authors did not look at any of the factors identified as risks for pneumonia in Langmore’s study [1].
  • An Australian study carried out at a tertiary hospital in regional Victoria [3] found that about 15% of the acute patients on a free-water protocol developed lung related complications (six patients: two with Alzheimer’s, two with Parkinsons, one with an Intellectual Disabiltiy, and one with Cancer; all were immobile or had poor mobility). The intervention group did drink >300mL more fluids on average than those on thickened fluids only; and was much happier about the fluids provided, their level of thirst and mouth cleanliness.
  • A much smaller follow-up to this study [4] found that restricting the protocol to those without poor/no mobility or severe degenerative neurological dysfunction, resulted in none of the intervention group developing pneumonia.
    • Neither of the papers noted if the patients with poor mobility/cognition were supervised when they access to free water – this is explicitly mentioned in the protocol for those with impulsivity.

Oral care is extremely important for reducing the risk of pneumonia:

  • An exciting study from Japan conducted in 1996 on 417 nursing home residents found that an aggressive oral care plan (nurses cleaned teeth after each meal and swabbed with povidone iodine when necessary. Dental hygienists provided weekly care) resulted in half as many patients dying from pneumonia as controls who were given business-as-usual care [5].
  • Nasogastric (NG) and percutaneous enterogastric (PEG) tube-fed patients are far more likely to develop potentially dangerous bacterial colonisations. A study of 215 patients from Israel, found that 81% of NGT-fed patients, and 51% of PED-fed patients had dangerous bacterial colonies in their oral cavity and pharynx; whereas only 17.5% of oral-fed patients did [6].

Implications for Practice

  • Given that the consequences of dehydration are severe, that only drinking thickened fluids decreases fluid intake, and that aspiration alone is generally insufficient to cause pneumonia, Free Water seems like a good idea.
  • Vigorous monitoring of oral health is vital for the success of a protocol.
  • Consideration must be given to cognition and mobility.


  1. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81
  2. 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. Neurorehabilitation and Neural Repair, 11(3), 139-148
  3. Karagiannis, M. J., Chivers, L., & Karagiannis, T. C. (2011). Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatr, 11, 9. doi: 10.1186/1471-2318-11-9
  4. Karagiannis, M., & Karagiannis, T. C. (2014). Oropharyngeal dysphagia, free water protocol and quality of life: an update from a prospective clinical trial. Hell J Nucl Med, 17 Suppl 1, 26-29.
  5. Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., . . . Oral Care Working, G. (2002). Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc, 50(3), 430-433.
  6. Leibovitz, A., Plotnikov, G., Habot, B., Rosenberg, M., & Segal, R. (2003). Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med Sci, 58(1), 52-55.

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