晚期慢性阻塞性肺病（COPD）患者常常面临复杂的医疗问题，简单的药物治疗无法达到最佳效果。为了应对初级呼吸道疾病本身及其系统性表现和共病所带来的重大负担，全面护理是必不可少的。这些问题在围加重期尤其明显，尤其是对于刚出院的患者来说。肺康复采用跨学科、以患者为中心的整体管理方法和综合护理，有助于加强护理的协调性，是解决这些复杂问题的有效方法。

关键字：慢性阻塞性肺病；综合护理；肺康复；护理协调

Abstract：

Patients with advanced chronic obstructive pulmonary disease (COPD) often face complex medical problems that cannot be optimally achieved with simple medical treatments. Comprehensive care is essential to address the significant burden of primary respiratory diseases themselves, their systemic manifestations and comorbidities. These problems are particularly pronounced during the peri-exacerbation phase, especially in patients who have recently been discharged from hospital. Pulmonary rehabilitation, which uses an interdisciplinary, patient-centered, holistic approach to management and integrated care, can help strengthen the coordination of care or transition to a chronic care model, and is an effective way to address these complex issues.

Keywords: Chronic obstructive pulmonary disease; integrated care; Pulmonary rehabilitation; Care coordination

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