本研究以国际健康残疾分类系统ICF为基本框架，以国际阻塞性肺疾病ICF（综合版）为基本内容，应用Delphi法构建慢性阻塞性肺疾病ICF核心要素评价体系，探索构建出一套完整的慢阻肺患者生理、心理、功能与社会参与状态的评估和风险管理系统，作为慢性呼吸疾病长期照护政策的参考；依据系统所筛选的条目和权重值，研制慢性阻塞性肺疾病ICF评定量表，通过信效度检验的方法，对量表的性能进行临床验证。在构建慢阻肺ICF核心要素评价体系的基础上，采用Meta分析和合成分析法构建慢阻肺ICF功能障碍风险评估模型，阐明慢阻肺患者功能障碍的机制，提供建立后续康复干预策略的临床思路；通过多学科专家小组访谈形式初步构建多学科协作式康复干预方案，为慢阻肺患者开展从轻度到极重度，从稳定期到急性加重期，从医院到居家的康复策略，并通过短期随机对照试验验证干预策略，为后续开展大规模多中心随机对照研究提供思路。

Based on ICF framework and obstructive pulmonary disease (comprehensive) core set, evaluations systems of chronic obstructive pulmonary disease (ICF) will be constructed by Delphi method, in order to set up a complete set of assessment and risk management systems for the physiological, psychological, functional and social participation of patients with chronic obstructive pulmonary disease, which will be a reference for long-term care policy for chronic respiratory diseases.According to the items and weights that are filtered by the system, develop the COPD rating scale, and verity the property of the assessment by reliability and variability methods. Both meta analysis and synthetic analysis methods will be used to construct COPD functional disorder with risk assessment model, to elucidate the mechanism of the dysfunction of patients with COPD , and to provide a clinical idea for the establishment of follow-up rehabilitation intervention strategies.The multidisciplinary collaborative rehabilitation intervention program was initially constructed through multidisciplinary expert group interviews， short-term randomized controlled trial will be conducted for patients with COPD from mild to extremely severe, from stable to acute exacerbations, from hospital to home rehabilitation strategies, to provide the idea for the follow-up of large-scale multicenter randomized controlled study in the future.