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This part reviews the management of chronic cough and proposes a management algorithm. Despite proven improvements in quality of life following chronic cough treatment, a clear understanding of the disease and the evidence for the efficacy of some treatments remain vague. Eight key questions regarding the treatment in the uncertain areas were systematically addressed based on the PICO framework and applying the GRADE system for evidence synthesis to provide the strength of recommendation and quality of evidence for key questions, with narrative components for the description of other chronic cough treatment including non-pharmacological therapy. Practical diagrams were developed to facilitate clinical decision-making on treatment. Our guideline introduces the concept of the cough management process for guiding practitioners to assess chronic cough using a holistic approach.

Chronic cough is a common clinical condition requiring comprehensive assessment. This review employs a symptom-focused approach, prioritizing the presenting symptom of "chronic cough" to mirror real-world clinical practice. Ten key questions regarding the investigations in the uncertain areas were systematically addressed based on the PICO framework and applying the GRADE system for evidence synthesis to provide the strength of recommendation and quality of evidence for key questions. Practical diagrams were developed to facilitate clinical decision-making. The initial evaluation involves screening for red flag signs requiring urgent attention, followed by a detailed history-taking and physical examination. A chest radiograph is recommended as the first-line investigation. The primary objective of the initial evaluation is to identify the cause and initiate appropriate treatment. If history and physical examination prove insufficient for a definitive diagnosis, referral to a specialist is advised for further specific testing. The recommendations on specific testing include fractional exhaled nitric oxide for cough variant asthma, nasal endoscopy or digital endoscopy (optional) for upper airway cough syndrome, paranasal sinus computed tomography (CT) for chronic rhinosinusitis, and laryngoscopy for hoarseness. Spirometry is for the diagnosis of obstructive airway diseases, and peak flow variability or bronchial challenge tests are complements particularly if asthma is suspected. Gastroesophageal reflux (GERD) investigations are for patients with chronic cough without typical GERD symptoms. Sinus radiographs and chest CT are not routinely recommended. Our guideline distinguishes itself by prioritizing a symptom-based clinical evaluation to guide clinicians toward the most probable diagnosis, streamlining the diagnostic process.

Background: Acute kidney injury and hyperchloremia are commonly present in critically ill septic patients. Our study goal was to evaluate the association of hyperchloremia and acute kidney injury in severe sepsis and septic shock patients., Methods: In this retrospective cohort study in a provincial tertiary care hospital, adult patients with severe sepsis or septic shock and serum chloride measurements were included. Serum chloride was measured on a daily basis for 48 hours. Primary outcome was development of acute kidney injury (AKI) and association of AKI and serum chloride parameters was analyzed., Results: A total of 240 patients were included in the study, 98 patients (40.8 %) had hyperchloremia. The incidence of acute kidney injury (AKI) was significantly higher in the hyperchloremia group (85.7 % vs 47.9 %; p < 0.001). Maximal chloride concentration in the first 48 hours ([Cl - ] max ) was significantly associated with AKI. In multivariate analysis, [Cl - ] max was independently associated with AKI [adjusted odds ratio (OR) for AKI = 1.28 (1.02-1.62); p = 0.037]. The increase in serum chloride (Δ[Cl - ] = [Cl - ] max - initial chloride concentration) demonstrated a dose-dependent relationship with severity of AKI. The mean Δ[Cl - ] in patients without AKI was 2.1 mmol/L while in the patients with AKI stage 1, 2 and 3 the mean Δ[Cl - ] was 5.1, 5.9 and 6.7 mmol/L, respectively. A moderate increase in serum chloride (Δ[Cl - ] ≥ 5 mmol/L) was associated with AKI [OR = 5.70 (3.00-10.82); p < 0.001], even in patients without hyperchloremia [OR = 8.25 (3.44-19.78); p < 0.001]., Conclusions: Hyperchloremia is common in severe sepsis and septic shock and independently associated with AKI. A moderate increase in serum chloride (Δ[Cl - ] ≥5 mmol/L) is associated with AKI even in patients without hyperchloremia.

Increased blood lactate concentration (hyperlactatemia) and lactic acidosis (hyperlactatemia and serum pH < 7.35) are common in patients with severe sepsis or septic shock and are associated with significant morbidity and mortality. In some patients, most of the lactate that is produced in shock states is due to inadequate oxygen delivery resulting in tissue hypoxia and causing anaerobic glycolysis. However, lactate formation during sepsis is not entirely related to tissue hypoxia or reversible by increasing oxygen delivery. In this review, we initially outline the metabolism of lactate and etiology of lactic acidosis; we then address the pathophysiology of lactic acidosis in sepsis. We discuss the clinical implications of serum lactate measurement in diagnosis, monitoring, and prognostication in acute and intensive care settings. Finally, we explore treatment of lactic acidosis and its impact on clinical outcome., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)