November 4

Don’t Go Chasing (Free Water) Protocols


Last week I shared a picture of what can happen when a patient is made strict NPO. It’s not great, and according to Feinberg, Knebl, and Tully (1996), the highest frequency of pneumonia occurred with patients on artificial feeding. Higher than those who were known to be aspirating.  So by recommending strict NPO are we decreasing the chance of a patient developing pneumonia? No. 

So what’s an alternative?

The Frazier Free Water Protocol

What is it? In very basic terms, it is a protocol that allows with patients on thickened liquids or those that are NPO to have regular, thin water. Of course there are guidelines for implementing the protocol. 

An instrumental swallow study must be completed. 

We need to know what is going on with the patient’s swallow. We need to know if there is a strategy or position that can increase the safety of the water intake. And of course we need the instrumental swallow study in order to develop an effective treatment plan. 

Oral Care is Incredibly Important

Oral care must be aggressive and frequent. If a patient has an oral infection, recommendations are usually to clear the infection before implementing the protocol. 

The Timing of Intake Matters

For NPO patients, water is allowed at all times. For those on an oral diet, water is allowed all the way up to a meal but not during meals, and water intake can be resumed 30 minutes following the meal. Snacks and medication administration count in the 30 minute rule as well. 

Educate, Educate, Educate

“So you know they are going to aspirate but you are still going to give them water?” This is a question you get almost every time the Frazier Free Water Protocol is recommended. Aspiration and aspiration pneumonia are not straight forward, black and white topics. We need to provide education about WHY the water is safe. Water is easily and quickly absorbed by the mucous membrane of the lungs. The pH of water is complimentary to the pH of body fluids. Multiple studies have offered evidence of no increase in pneumonia when the protocol is followed. Tap water in the US is generally very safe and pathogen free. If you practice in a country where this is not the case, bottled or filtered water would be recommended. 

So what are the benefits of the Frazier Free Water Protocol?

-Reduced chances for dehydration 

-Increased compliance with dysphagia program and recommendations 

-Improved quality of life

-May decrease the amount of time before the patient no longer aspirates thin liquids (mixed results here)

Anecdotally, I feel that most patients really appreciate being able to have water. It quenches thirst and moistens their mouth much better than thickened liquids. And no one likes thickened water (or at least no one I have come across) so I have noticed more intake of thickened juices instead of water which can add a lot of sugar to their diet. 

Also, how do we expect patients to improve their safety with swallowing thin liquids if we never allow them to practice?

Do you implement the Frazier Free Water Protocol? Or are you in disagreement with it? What challenges and/or benefits have you encountered with the protocol? Let me know!




Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104–109.

Panther, K. (2005). The Frazier free water protocol. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14(1), 4–9.


Clinical Focus, Dysphagia, FEES

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