Abstract: Chronic obstructive pulmonary disease（COPD）is a common and frequently-occurring disease in clinical practice.In China，the number of COPD patients is nearly 100 million，and COPD constitutes another chronic disease with heavy disease burden besides hypertension and diabetes.However，unlike hypertension and diabetes，COPD has not received enough attention from patients，doctors and the government，and its early diagnosis and standardized diagnosis and treatment levels are still relatively low.General practitioners play important roles in the prevention，control and management of COPD，especially in early screening，management of patients in stable phase，as well as pulmonary rehabilitation.And it is imminent to establish a hospital-community-family COPD prevention and control model，conduct the general-specialty care，and develop standardized prevention and control of COPD in primary care.This paper discusses the role of general practitioners in the early diagnosis and management of COPD.

Key words: Pulmonary disease, chronic obstructive；Chronic disease；General practitioners；Progressive patient care；Community health services；Disease management

摘要： 慢性阻塞性肺疾病是临床常见病、多发病之一。目前我国慢性阻塞性肺疾病患者数量接近1亿，成为继高血压、糖尿病之后另一疾病负担重大的慢性疾病，但与高血压、糖尿病管理规模和管理水平相比，慢性阻塞性肺疾病的早期诊断和规范化诊治水平较低，且尚未得到患者、医生及政府足够重视。全科医生在慢性阻塞性肺疾病的防控、管理尤其是慢性阻塞性肺疾病的早期筛查、稳定期患者管理及肺康复中发挥着重要作用，建立医院-社区-家庭慢性阻塞性肺疾病防控模式、开展专科-全科医生之间的分级诊疗及基层医疗机构慢性阻塞性肺疾病规范防控迫在眉睫。本文以慢性阻塞性肺疾病为例，就全科医生在慢性病早期诊断和管理中的作用进行了探讨。

关键词: 肺疾病, 慢性阻塞性肺疾病, 慢性病, 全科医生, 患者分级医疗, 社区卫生服务, 疾病管理