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Key Points

  • Integrated care for chronic obstructive pulmonary disease (COPD) involves the patient and a team of clinical professionals cooperating with secondary care and rehabilitation services.
  • Optimal disease management involves redesigning standard medical care to integrate rehabilitative elements into a system of patient self-management and regular exercise.
  • Case finding is a simple and effective means of enhancing the diagnosis of COPD in primary care. Use of spirometry by primary care providers is recommended to detect airways obstruction and facilitate smoking cessation.
  • A diagnosis of COPD is confirmed by spirometry, which can be performed in a primary care setting if personnel are specifically trained and quality assurance is maintained.
  • COPD is often accompanied by deconditioning, comorbid illnesses and symptoms of depression. Even in patients with mild disease, health status can be substantially compromised.
  • The majority of COPD exacerbations are managed at home by the patient or the primary care team. Approximately 50% of exacerbations are not reported to clinicians.
  • Patients with COPD should be made more aware of the symptoms of an exacerbation and be encouraged to report these early to clinicians. Conversely, physicians should make use of the experience of the individual patient and ask for early signs of an exacerbation.
  • In most cases, short courses of oral corticosteroids should be initiated at first signs of an exacerbation.
  • Most of the professional care provided to patients reaching end of life is given by primary care teams.
  • A disease management flow diagram for integrated care of COPD is introduced.

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