Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review


The Frazier Free Water Protocol was developed with the aim of providing patients with dysphagia an option to consume thin (i.e. unthickened) water in-between mealtimes. A systematic review was conducted of research published in peer-reviewed journals. An electronic search of the EMBASE, CINAHL and MEDLINE databases was completed up to July 2016. A total of 8 studies were identified for inclusion: 5 randomised controlled trials, 2 cohort studies with matched cases and 1 single group pre-post intervention prospective study. A total of 215 rehabilitation inpatients and 30 acute patients with oropharyngeal dysphagia who required thickened fluids or were to remain ‘nil by mouth’, as determined by bedside swallow assessment and/or videofluoroscopy/fiberoptic endoscopic evaluation of swallowing, were included. Meta-analyses of the data from the rehabilitation studies revealed (1) low-quality evidence that implementing the protocol did not result in increased odds of having lung complications and (2) low-quality evidence that fluid intake may increase. Patients’ perceptions of swallow-related quality of life appeared to improve. This review has found that when the protocol is closely adhered to and patients are carefully selected using strict exclusion criteria, including an evaluation of their cognition and mobility, adult rehabilitation inpatients with dysphagia to thin fluids can be offered the choice of implementing the Free Water Protocol. Further research is required to determine if the Free Water Protocol can be implemented in settings other than inpatient rehabilitation.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Snyder NA, Feigal DW, Arieff AL. Hypernatremia in elderly patients. A heterogeneous, morbid, and iatrogenic entity. Ann Intern Med. 1987;107:309–19.

  2. 2.

    Shireffs SM, Merson SJ, Fraser SM, Archer DT. The effects of fluid restriction on hydration status and subjective feelings in man. Br J Nutr. 2004;91(6):951–8.

  3. 3.

    Kelly J, Hunt BJ, Lewis RR, Swaminathan R, Moody A, Seed PT, Rudd A. Dehydration and venous thromboembolism after acute stroke. QJM. 2004;97(5):293–6.

  4. 4.

    Warren JL, Bacon WE, Harris T, McBean AM, Foley DJ, Phillips C. The burden and outcomes associated with dehydration among US elderly. Am J Public Health. 1991;84:1265–9.

  5. 5.

    Altman KW, Gou-Peri Y, Schaefer S. Consequence of dysphagia in the hospitalised patient. Arch Otolaryngol Head Neck Surg. 2010;136(8):784–9.

  6. 6.

    Marik PE. Aspiration pneumonitis and pneumonia: a clinical review. N Engl J Med. 2001;344:665–72.

  7. 7.

    Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia. 1998;13(2):69–81.

  8. 8.

    Hibberd J, Fraser J, Chapman C, McQueen H, Wilson A. Can we use influencing factors to predict aspiration pneumonia in the United Kingdom? Multidiscip Respir Med. 2013;8(1):39.

  9. 9.

    Vivanti AP, Campbell KL, Suter MS, Hannan-Jones MT, Hulcombe JA. Contribution of thickened drinks, food and enteral parenteral fluids of fluid intake in hospitalized patients with dysphagia. J Hum Nutr Diet. 2009;22:148–55.

  10. 10.

    Kuhlemeier KV, Palmer JB, Rosenberg D. Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients. Dysphagia. 2001;16(2):119–22.

  11. 11.

    Logemann J. Evaluation and treatment of swallowing disorders/edition 2. Austin: PRO-ED; 1998.

  12. 12.

    Dantas RO, Kern MK, Massey BT, Dodds WJ, Kahrilas PJ, Brasseur JG, Cook IJ, Lang IM. Effect of swallowed bolus variables on oral and pharyngeal phases of swallowing. Am J Physiol. 1990;258(5):G675–81.

  13. 13.

    Low J, Wyles C, Wilkinson T, Sainsbury R. The effect of compliance on clinical outcome for patients with dysphagia on videofluoroscopy. Dysphagia. 2001;16(2):123–7.

  14. 14.

    Garcia J, Chambers E, Molander M. Thickened liquids: practice patters of speech-language pathologists. Am J Speech Lang Pathol. 2005;14(1):4–13.

  15. 15.

    Colodny N. Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist. Am J Speech Lang Pathol. 2005;14:61–70.

  16. 16.

    Leiter AE, Windsor J. Compliance of geriatric dysphagic patients with safe-swallowing instructions. J Med Speech Lang Pathol. 1996;4:289–99.

  17. 17.

    Langmore SE. Why I like the free water protocol. SIG 13 perspectives on swallowing and swallowing disorders. Dysphagia. 2011;20:116–20.

  18. 18.

    Holas MA, DePippo KL, Reding MJ. Aspiration and relative risk of medical complications following stroke. Arch Neurol. 1994;51(10):1051–3.

  19. 19.

    Effros RM, Jacobs ER, Schapira RM, Biller J. Response of the lungs to aspiration. Am J Med. 2000;108(Suppl 4a):15S–9S.

  20. 20.

    Panther K. The Frazier free water protocol. SIG 13 perspectives on swallowing and swallowing disorders. Dysphagia. 2005;14:4–9.

  21. 21.

    Terpenning M, Bretz W, Lopatin D, Langmore S, Dominguez B, Loesche W. Bacterial colonization of saliva and plaque in the elderly. Clin Infect Dis. 1993;16(Suppl 4):S314–6.

  22. 22.

    Van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013;30(1):3–9.

  23. 23.

    Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(2):191–5.

  24. 24.

    Azarpazhooh A, Leake L. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77(9):1465–82.

  25. 25.

    Roberts N, Moule P. Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates. Nurs Crit Care. 2011;16:295–302.

  26. 26.

    Sato M, Yoshihara A, Miyazaki H. Preliminary study on the effect of oral care on recovery from surgery in elderly patients. J Oral Rehabil. 2006;33:820–6.

  27. 27.

    Bronson-Lowe C, Leising K, Bronson-Lowe D, Lanham S. Effects of a free water protocol for patients with dysphagia. Dysphagia. 2008;23:423–36.

  28. 28.

    Stewart RJ, Mehta SA, Veltman LE, Oleszek MR, Brady SL, Escobar NG. Water access for individuals with dysphagia who aspirate: research challenges. Brain Inj. 2012;26(4–5):309–792.

  29. 29.

    Kenedi H, Foreman M, Graybeal D, Reynolds J, Campbell JB, Santos TO, Gibson M, Burgardt M. Positive and negative clinical indicators of the free water protocol in an acute care setting: two pilot studies North American brain injury society’s eleventh annual conference on brain injury. J Head Trauma Rehabil. 2013;28(5):31–65.

  30. 30.

    Pooyania S, Galimova L, Buchel C, Daun R, Lenton L. Effects of a free water protocol on inpatients in a neurological rehabilitation setting. Stroke. 2013;44:174–228.

  31. 31.

    Karagiannis C. Quality of life for patients with dysphagia: what really matters? Dysphagia. 2013;25:354–62.

  32. 32.

    Carlaw, et al. Implementation of a water protocol in a rehabilitation setting for clients with thin liquid dysphagia: preliminary results of a randomized trial. Dysphagia. 2010;25:354–98.

  33. 33.

    Carlaw C, Finlayson H, Kathleen B, Tiffany V, Caroline M, Coney D, Steele C. A randomized controlled trial of a water protocol for clients with thin liquid dysphagia. Dysphagia. 2009;24:461–84.

  34. 34.

    Karagiannis M. Quality of life for patients with dysphagia: what really matters? Dysphagia. 2010;25:354–98.

  35. 35.

    Becker A, Tews L, Lemke J. ‘An oral water protocol in rehabilitation patients with dysphagia for liquids’. Paper presented at the American Speech-Language Hearing Association Convention, Chicago. 2008. http://www.asha.org/Events/convention/handouts/2008/1877_Tews_Lisa.htm.

  36. 36.

    Carlaw C, Steele C. Implementation of a water protocol in a rehabilitation setting. Paper presented at the American Speech-Language Hearing Association Convention, New Orleans, Louisiana. 2009. http://www.asha.org/Events/convention/handouts/2009/1977_Carlaw_Caren.

  37. 37.

    Schwartzentruber. A The effects of a free-fluid protocol on individuals with thin-liquid dysphagia. University of Western Ontario. 2011. https://www.uwo.ca/fhs/csd/ebp/reviews/2010-11/Schwartzentruber.pdf. Accessed 30 June 2015.

  38. 38.

    Weber V. The challenges of initiating the Frazier Water Protocol on an acute care stroke unit. Inst Nurs Newsl. 2009;5(3):10.

  39. 39.

    Mosheim, J. Frazier Water Protocol 16:24:6. 2006. http://speech-language-pathology-audiology.advanceweb.com/Article/Frazier-Water-Protocol-1.aspx Accessed 30 June 2015.

  40. 40.

    Coyle JL. Water, water everywhere, but why? Argument against free water protocols. SIG 13 perspectives on swallowing and swallowing disorders. Dysphagia. 2011;20:109–15.

  41. 41.

    Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA group preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

  42. 42.

    Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. J Epidemiol Community Health. 1998;52:377–84.

  43. 43.

    Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care. 2013;28(2):216.

  44. 44.

    Kennelly J. Methodological approach to assessing the evidence. In: Handler A, Kennelly J, Peacock N, editors. Reducing racial/ethnic disparities in reproductive and perinatal outcomes: the evidence from population-based interventions. Springer: Chicago; 2011. p. 7–19.

  45. 45.

    Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. http://www.handbook.cochraneorg.

  46. 46.

    Karagiannis MJ, Chivers L, Karagiannis TC. Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatr. 2011;1(11):9.

  47. 47.

    Karagiannis M, Karagiannis TC. Oropharyngeal dysphagia, free water protocol and quality of life: an update from a prospective clinical trial. Hellenic J Nucl Med. 2014;17:26–9.

  48. 48.

    GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490.

  49. 49.

    Garon BR, Engle M, Ormiston C. A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Journal of Neurol Rehabil. 1997;11(3):139–48.

  50. 50.

    Carlaw C, Finlayson H, Beggs K, Visser T, Marcoux C, Coney D, Steele CM. Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia. 2012;27(3):297–306.

  51. 51.

    Murray J, Doeltgen S, Miller M, Scholten I. Does a water protocol improve the hydration and health status of individuals with thin liquid aspiration following stroke? A randomized controlled trial. Dysphagia. 2016;31:424–33.

  52. 52.

    Pooyania S, Vandurme L, Daun R, Buchel C. Effects of a Free Water Protocol on inpatients in a neuro-rehabilitation setting. Open J Ther Rehabil. 2015;2015(3):132–8.

  53. 53.

    Frey KL, Ramsberger G. Comparison of outcomes before and after implementation of a water protocol for patients with cerebrovascular accident and dysphagia. J Neurosci Nurs. 2011;43(3):165–71.

  54. 54.

    Bernard S, Loeslie V, Rabatin J. Brief report—use of a modified Frazier Water Protocol in critical illness survivors with pulmonary compromise and dysphagia: a pilot study. Am J Occup Ther. 2016;70(1):1–5.

Download references

Author information

Correspondence to Anna Gillman.

Ethics declarations

Conflict of interests

The authors have no conflicts of interest to declare.


Appendix 1

Search Terms and Keywords

Dysphag*, deglutition, aspiration, laryngeal penetration, swallow*, thickened fluid*, thick fluid*, thickened drink*, thick drink*, modified fluid*, modified drink*, nil by mouth, nil oral, NBM, water protocol*, liquid protocol*, fluid protocol*, regular fluid*, thin liquid*, free liquid*, regular liquid*, risk feed*, frazier*, frasier*, free fluid*, free water, thin fluid*, water, sip*, risk*, benefit*, positiv*, negativ*, outcome*, effectiv*, advantag*, disadvantag*, quality of life, chest infection*, respiratory tract infection*, LRTI, URTI, RTI, mortality rate*, rate* of mortality, complian*, compl*, cost*, satisf*, IV fluid*, intravenous fluid*.

Appendix 2

Downs and black quality assessment Karagiannis et al. [46] Carlaw et al. [50] Garon et al. [49] Karagiannis et al. [47] Frey et al. [53] Murray et al. [51] Pooyania et al. [52] Bernard et al. [54]
1. Is the hypothesis/aim/objective of the study clearly described? 1 1 1 1 1 1 1 1
2. Are outcomes to be measured clearly described in Intro/Methods? 1 1 1 1 1 1 1 1
3. Are patient characteristics clearly described? 1 1 1 1 1 1 1 1
4. Are the interventions of interest clearly described? 1 1 1 1 1 1 1 1
5. Are the distributions of principal confounders in each group of subjects to be compared clearly described? 1 1 1 1 1 1 0 1
6. Are the main findings of the study clearly described? 1 1 1 1 1 1 1 0
7. Does the study provide estimates of the random variability in the data for the main outcomes? 1 1 1 1 0 1 1 0
8. Have all important adverse events that may be a consequence of the intervention been reported? 1 1 1 1 1 1 1 1
9. Have the characteristics of patients lost to follow-up been described? 1 1 0 1 0 1 1 1
10. Have actual probability values been reported for the main outcomes except where the probability values is less that 0.001? 1 1 1 1 0 1 1 0
11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited? 1 1 1 1 1 1 0 1
12. Were those subjects who were prepared to participate representative of the entire population from which they were recruited? 0 1 1 1 1 1 0 0
13. Were the staff, places and facilities where the patients were treated, representative of the treatment the majority of patients receive? 1 1 1 1 1 1 1 1
14. Was an attempt made to blind study subjects to the intervention they have received? 0 0 0 0 0 0 0 0
15. Was an attempt made to blind those measuring the main outcomes of the intervention? 1 0 0 0 0 0 0 0
16. If any of the results of the study were based on ‘data dredging’, was this made clear? 1 1 1 1 0 1 0 0
17. In trials and cohort studies, do the analysis adjust for different lengths of follow-up of patients of in case–control studies is the time period between the intervention and outcome the same for cases and controls? 1 1 1 1 1 1 1 1
18. Were the statistical tests used to assess the main outcomes appropriate? 1 1 1 1 1 1 0 0
19. Was compliance with the intervention reliable? 1 1 1 1 1 1 1 1
20. Were the main outcome measures used accurate (valid and reliable)? (were they clearly described?) 1 1 1 1 0 1 1 0
21. Were the patients in different intervention groups (trials and cohorts) or were the cases and controls (case–control studies) recruited from the same population? 1 1 1 1 1 1 1 1
22. Were study subjects in different intervention groups (trials and cohort studies) or were the case and controls (case–control studies) recruited over the same period of time? 1 1 1 1 0 1 1 0
23. Were subjects randomised to intervention groups? 1 1 1 0 0 1 0 0
24. Was the randomised intervention assignment concealed from both parties and health care staff until recruitment was complete and irrevocable? 1 0 0 0 0 0 1 0
25. Was there adequate adjustment for confounding in the analyses from which the main findings were drawn? 1 1 0 1 1 1 0 0
26. Were losses of patients to follow-up taken into account? 1 1 0 1 0 1 1 1
27. Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance is less than 5%? 5 5 3 3 3 5 1 0
Score 29 28 23 25 18 28 23 13

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gillman, A., Winkler, R. & Taylor, N.F. Implementing the Free Water Protocol does not Result in Aspiration Pneumonia in Carefully Selected Patients with Dysphagia: A Systematic Review. Dysphagia 32, 345–361 (2017). https://doi.org/10.1007/s00455-016-9761-3

Download citation


  • Frazier Free Water Protocol
  • Dysphagia
  • Aspiration pneumonia
  • Deglutition
  • Deglutition disorders
  • Speech language pathology