BACKGROUND: Chronic cough is a common but challenging clinical condition that can adversely affect the safety of awake surgical endeavors such as awake craniotomy (AC). This case lesson highlighted a patient with severe refractory chronic cough undergoing AC for resection of a recurrent left frontal, insula, anterior temporal anaplastic ependymoma of the eloquent cortex.
METHODS: The patient was successfully managed using a multifaceted medical treatment regimen combined with preoperative and intraoperative cough suppression therapy with a speech-language pathologist. The patient coughed only once intraoperatively and had a positive outcome.
CONCLUSIONS: Chronic cough is often multifactorial and requires a multifaceted treatment approach. Despite this challenge, select patients can successfully be navigated through AC with appropriate treatment for their condition. A review of neurogenic cough and modern treatments, which were used in this patient and would be helpful to neurologists or neurosurgeons, are also discussed.

BACKGROUND: Impaired respiratory and swallow function in patients with intensive care unit-acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.
OBJECTIVE: The aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.
METHODS: Case 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy.
CONCLUSIONS: At baseline, the PEF score of case 1 was 41% (predicted age-height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.
CONCLUSIONS: The addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.