整合照护与智慧赋能下慢性阻塞性肺疾病共病护理管理体系的构建

doi:10.19983/j.issn.2096-8493.20260087

摘要/Abstract

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R563

蒋静, 鲁秀玲, 张焱, 吴妮慧, 张晓旭, 顾芬. 整合照护与智慧赋能下慢性阻塞性肺疾病共病护理管理体系的构建[J]. 结核与肺部疾病杂志, 2026, 7(3): 277-283. doi: 10.19983/j.issn.2096-8493.20260087

参考文献 46

[1]	Christenson SA, Smith BM, Bafadhel M, et al. Chronic obstructive pulmonary disease. Lancet, 2022, 399(10342): 2227-2242. doi:10.1016/S0140-6736(22)00470-6. pmid: 35533707
[2]	World Health Organization. Chronic obstructive pulmonary disease (COPD). Geneva: World Health Organization, 2024.
[3]	Boers E, Barrett M, Su JG, et al. Global burden of chronic obstructive pulmonary disease through 2050. JAMA Netw Open, 2023, 6(12): e2346598. doi:10.1001/jamanetworkopen.2023.46598.
[4]	Fabbri LM, Celli BR, Agustí A, et al. COPD and multimorbidity: recognising and addressing a syndemic occurrence. Lancet Respir Med, 2023, 11(11):1020-1034. doi:10.1016/S2213-2600(23)00261-8. pmid: 37696283
[5]	Kahnert K, Jörres RA, Behr J, et al. The diagnosis and treatment of COPD and its comorbidities. Dtsch Arztebl Int, 2023, 120(25):434-444. doi:10.3238/arztebl.m2023.027.
[6]	Crisafulli E, Sartori G, Vianello A, et al. Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both. Intern Emerg Med, 2023, 18(2): 523-534. doi:10.1007/s11739-023-03207-w. pmid: 36773107
[7]	Anghel L, Ciubară A, Patraş D, et al. Chronic obstructive pulmonary disease and type 2 diabetes mellitus: complex interactions and clinical implications. J Clin Med, 2025, 14(6): 1809. doi:10.3390/jcm14061809.
[8]	Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Obstructive Lung Disease 2026 Report. 2025-11-14.
[9]	Cazzola M, Bajpai J, Calzetta L, et al. GOLD 2026: transforming COPD management with early intervention, multi-dimensional assessment, and personalized care. Drugs, 2026, 86(5):581-597. doi:10.1007/s40265-026-02303-3.
[10]	Mateo-Abad M, González N, Fullaondo A, et al. Impact of the CareWell integrated care model for older patients with multimorbidity: a quasi-experimental controlled study in the basque country. BMC Health Serv Res, 2020, 20(1): 613. doi:10.1186/s12913-020-05473-2. pmid: 32620116
[11]	Guan X, Xia Y, Ai J, et al. Effects of integrated care on patients with COPD and comorbidities: a systematic review. Ther Adv Respir Dis, 2026, 20:17534666251414315. doi:10.1177/17534666251414315.
[12]	Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J, 2021, 42(34): 3227-3337. doi:10.1093/eurheartj/ehab484. pmid: 34458905
[13]	de Miguel-Díez J, Núñez Villota J, Santos Pérez S, et al. Multidisciplinary management of patients with chronic obstructive pulmonary disease and cardiovascular disease. Arch Bronconeumol, 2024, 60(4):226-237. doi:10.1016/j.arbres.2024.01.013.
[14]	Natali D, Cloatre G, Hovette P, et al. Screening for comorbidities in COPD. Breathe(Sheff), 2020, 16(1): 190315. doi:10.1183/20734735.0315-2019.
[15]	Moretta P, Cavallo ND, Candia C, et al. Psychiatric disorders in patients with chronic obstructive pulmonary disease: clinical significance and treatment strategies. J Clin Med, 2024, 13(21): 6418. doi:10.3390/jcm13216418.
[16]	刘升明. 《GOLD 2026报告》关于慢性阻塞性肺疾病诊断、治疗、管理及预防全球策略更新要点解读. 实用医学杂志, 2026, 42(4): 541-550. doi:10.3969/j.issn.1006-5725.2026.04.001.
[17]	Celli BR, Fabbri LM, Yohannes AM, et al. A person-centred clinical approach to the multimorbid patient with COPD. Eur J Intern Med, 2025, 140: 106424. doi:10.1016/j.ejim.2025.07.020.
[18]	Groenewegen A, Zwartkruis VW, Rienstra M, et al. Diagnostic yield of a proactive strategy for early detection of cardiovascular disease versus usual care in adults with type 2 diabetes or chronic obstructive pulmonary disease in primary care in the Netherlands (RED-CVD): a multicentre, pragmatic, cluster-randomised, controlled trial. Lancet Public Health, 2024, 9(2): e88-e99. doi:10.1016/S2468-2667(23)00269-4. pmid: 38134944
[19]	刘建材, 郑涵尹, 李传芬, 等. 慢性阻塞性肺疾病管理模式及发展趋势. 中国慢性病预防与控制, 2022, 30(7): 541-544. doi:10.16386/j.cjpccd.issn.1004-6194.2022.07.014.
[20]	耿昌芳, 虞嘉, 黄维. 以专科护士为主导的多学科协作团队对老年COPD患者康复的影响. 齐鲁护理杂志, 2022, 28(19): 154-156. doi:10.3969/j.issn.1006-7256.2022.19.052.
[21]	张晓旭, 朱晓筱, 张焱, 等. 慢性阻塞性肺疾病患者肺康复护理管理的现状及思考. 结核与肺部疾病杂志, 2025, 6(3): 249-255. doi:10.19983/j.issn.2096-8493.20250044.
[22]	Rochester CL, Alison JA, Carlin B, et al. Pulmonary rehabilitation for adults with chronic respiratory disease: An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med, 2023, 208(4): e7-e26. doi:10.1164/rccm.202306-1066ST.
[23]	徐娜平, 张野, 刘贤亮, 等. 老年慢性阻塞性肺疾病患者的综合家庭肺康复研究. 护理学杂志, 2024, 39(9): 108-111. doi:10.3870/j.issn.1001-4152.2024.09.108.
[24]	Li Y, Gao H, Zhao L, et al. Osteoporosis in COPD patients: Risk factors and pulmonary rehabilitation. Clin Respir J, 2022, 16(7): 487-496. doi:10.1111/crj.13514. pmid: 35688435
[25]	Dennett EJ, Janjua S, Stovold E, et al. Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review. Cochrane Database Syst Rev, 2021, 7(7): CD013384. doi:10.1002/14651858.CD013384.pub2.
[26]	Machado FVC, Coninx K, Neunhaeuserer D, et al. Tailored exercise prescription for people with COPD and clinically relevant comorbidities: a consensus statement of the EXPERT working group and experts in pulmonary rehabilitation. Sports Med, 2026, 56(1): 97-116. doi:10.1007/s40279-025-02353-9.
[27]	祁莉, 张雷, 漆毅, 等. 心肺康复运动对老年慢性阻塞性肺疾病并发慢性心力衰竭患者的效果. 中国康复理论与实践, 2026, 32(2): 191-197. doi:10.3969/j.issn.1006-9771.2026.02.008.
[28]	Hansen D, Beckers P, Neunhäuserer D, et al. Standardised exercise prescription for patients with chronic coronary syndrome and/or heart failure: a consensus statement from the EXPERT working group. Sports Med, 2023, 53(11): 2013-2037. doi:10.1007/s40279-023-01909-x.
[29]	张艳红, 朱丽群, 米元元, 等. 慢性阻塞性肺疾病患者营养管理的最佳证据总结. 护士进修杂志, 2022, 37(4): 322-327. doi:10.16821/j.cnki.hsjx.2022.04.007.
[30]	Jenkins AR, Gaynor-Sodeifi K, Lewthwaite H, et al. Efficacy of interventions to alter measures of fat-free mass in people with COPD: a systematic review and meta-analysis. ERJ Open Res, 2023, 9(4): 00102-2023. doi:10.1183/23120541.00102-2023.
[31]	Beijers RJHCG, Steiner MC, Schols AMWJ. The role of diet and nutrition in the management of COPD. Eur Respir Rev, 2023, 32(168): 230003. doi:10.1183/16000617.0003-2023.
[32]	郭寒冰, 王道协, 侯笑颜, 等. 肺康复训练对中重度慢阻肺合并焦虑、抑郁患者的干预作用. 国际精神病学杂志, 2025, 52(6): 1946-1949, 1953. doi:10.3969/j.issn.1673-2952.2025.06.065.
[33]	Chen X, Guo Y, Zhang T, et al. Effects of cognitive behavioral therapy in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Worldviews Evid Based Nurs, 2024, 21(3): 288-306. doi:10.1111/wvn.12705.
[34]	Taylor SJC, Sohanpal R, Steed L, et al. Tailored psychological intervention for anxiety or depression in COPD (TANDEM): a randomised controlled trial. Eur Respir J, 2023, 62(5): 2300432. doi:10.1183/13993003.00432-2023.
[35]	Mclnerney GE, Muellers K, O’Conor R, et al. Concordance of patients’ beliefs about chronic obstructive pulmonary disease, their comorbidities, and their medications. Patient Educ Couns, 2020, 103(4): 677-681. doi:10.1016/j.pec.2019.11.016.
[36]	Schrijver J, Effing TW, Brusse-Keizer M, et al. Predictors of patient adherence to COPD self-management exacerbation action plans. Patient Educ Couns, 2021, 104(1): 163-170. doi:10.1016/j.pec.2020.06.015. pmid: 32616320
[37]	Ansari S, Hosseinzadeh H, Dennis S, et al. Activating primary care COPD patients with multi-morbidity through tailored self-management support. NPJ Prim Care Respir Med, 2020, 30(1): 12. doi:10.1038/s41533-020-0171-5.
[38]	Saxena FE, Bierman AS, Glazier RH, et al. Association of early physician follow-up with readmission among patients hospitalized for acute myocardial infarction, congestive heart failure, or chronic obstructive pulmonary disease. JAMA Netw Open, 2022, 5(7): e2222056. doi:10.1001/jamanetworkopen.2022.22056.
[39]	Kuan V, Denaxas S, Patalay P, et al. Identifying and visualising multimorbidity and comorbidity patterns in patients in the English national health service: a population-based study. Lancet Digit Health, 2023, 5(1): e16-e27. doi:10.1016/S2589-7500(22)00187-X.
[40]	Spoladore D, Colombo V, Fumagalli A, et al. An ontology-based decision support system for tailored clinical nutrition recommendations for patients with chronic obstructive pulmonary disease: development and acceptability study. JMIR Med Inform, 2024, 12: e50980. doi:10.2196/50980.
[41]	Domínguez J, Prociuk D, Marovic'B, et al. ROAD2H: development and evaluation of an open-source explainable artificial intelligence approach for managing co-morbidity and clinical guidelines. Learn Health Syst, 2024, 8(2): e10391. doi:10.1002/lrh2.10391.
[42]	Gloeckl R, Spielmanns M, Stankeviciene A, et al. Smartphone application-based pulmonary rehabilitation in COPD: a multicentre randomised controlled trial. Thorax, 2025, 80(4): 209-217. doi:10.1136/thorax-2024-221803.
[43]	Huang X, Song X, Sun M, et al. Effectiveness of digital co-creation platform in remote pulmonary rehabilitation for older adults with chronic obstructive pulmonary disease: a randomized controlled trial. Front Public Health, 2025, 13: 1708607. doi:10.3389/fpubh.2025.1708607.
[44]	Shah AJ, Althobiani MA, Saigal A, et al. Wearable technology interventions in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. NPJ Digit Med, 2023, 6(1): 222. doi:10.1038/s41746-023-00962-0. pmid: 38012218
[45]	黎卓珩, 傅雅倩, 黄卓尔, 等. 慢性阻塞性肺疾病患者远程康复体验的系统评价与Meta整合. 军事护理, 2024, 41(4): 108-112. doi:10.3969/j.issn.2097-1826.2024.04.026.
[46]	Salgado R, Fernandes H, de Goumoëns V, et al. Effectiveness of self-management digital interventions for improving health-related outcomes in patients with chronic obstructive pulmonary disease: an umbrella review protocol. JBI Evid Synth, 2025, 23(6): 1246-1256. doi:10.11124/JBIES-24-00195.

整合照护与智慧赋能下慢性阻塞性肺疾病共病护理管理体系的构建

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