The Current Status, Challenges, and Optimization Strategies for Self-Management in Patients with COPD: A Review

Abstract

This article aims to review the current status, challenges, and optimization strategies of self-management in patients with Chronic Obstructive Pulmonary Disease (COPD). As a core component of comprehensive COPD treatment, self-management plays a key role in controlling symptoms, preventing acute exacerbations, improving quality of life, and reducing the healthcare burden. This narrative review comprehensively outlines the core definitions, current implementation models, key influencing factors, and evaluation systems of self-management, and provides an in-depth analysis of the current bottlenecks in patient adherence, knowledge and skill acquisition, psychosocial support, and integration of medical resources. Based on these findings, this article proposes the integration of behavioral change theory, digital health technologies (such as mobile applications, remote monitoring), home monitoring and early warning systems, and minimal resource rehabilitation interventions as strategic approaches to overcome these barriers. This review concludes that building a personalized, technology-enabled, and sustainable support system is crucial for improving the effectiveness of COPD self-management and reducing the healthcare burden.

Introduction

Chronic obstructive pulmonary disease (COPD) stands as a paramount driver of global disability and death.¹ Characterized by a protracted trajectory and a susceptibility to recurring acute flare-ups, the illness exacts a heavy toll on individuals, households, and society at large. Data from the Global Burden of Disease Study reveal that COPD affects over 500 million individuals, ranking as the third leading cause of mortality worldwide; its socioeconomic and health ramifications are profound, with populations in low- and middle-income nations bearing the brunt of the impact.² While China has witnessed a downward trend in the overall COPD burden over the last thirty years, those aged 40 and older remain the primary demographic in its grip.³ The burden of COPD extends beyond elevated mortality figures to include severe symptomatic distress, frequent exacerbations, diminished quality of life, and substantial utilization of medical resources.^4,5 Furthermore, COPD frequently coexists with an array of chronic conditions—including cardiovascular diseases, osteoporosis, lung cancer, and metabolic syndrome—a comorbidity landscape that further complicates diagnosis, treatment, and prognosis, thereby increasing management complexity.⁶

The conventional hospital-centric healthcare framework often falters when attempting to satisfy the demands of chronic ailments like COPD, which necessitate sustained, continuous oversight. Consequently, self-management paradigms that prioritize active patient engagement are receiving growing attention.⁷ Self-management denotes the capacity of patients, under the mentorship of healthcare providers, to navigate disease symptoms, treatments, and physiological and psychosocial shifts while recalibrating their lifestyles.⁸ For those living with COPD, effective self-management constitutes a multidimensional, holistic endeavor encompassing critical domains such as medication adherence, symptom surveillance, energy conservation strategies, breathing exercises, nutritional stewardship, smoking cessation maintenance, and the early detection and response to acute exacerbations.⁹

Although self-management is known to bolster health-related quality of life (HRQoL) and curb the likelihood of respiratory-related hospitalizations,⁸ its uptake in clinical settings remains hampered by a thicket of barriers: patients often lack awareness or requisite skills, support systems are fragmented, and interventions suffer from poor standardization.¹⁰ Self-management behaviors among COPD patients are generally suboptimal, hindered by factors such as age, educational background, family dynamics, and the extent of social support.¹¹ Concurrently, the efficacy of these efforts hinges deeply on how patients perceive their disease, their level of motivation, and their health literacy.^12,13

The recent surge in mobile health (mHealth), remote monitoring, and artificial intelligence (AI) has ushered in new paradigms, offering substantial promise for COPD self-management.^14,15 Digital health interventions—ranging from smartphone applications and wearable sensors to web-based platforms—can fortify patient self-efficacy and spur active participation through features like symptom tracking, medication prompts, personalized action plans, and remote rehabilitation support.¹⁶ Specifically, smartphone applications empower COPD patients by cultivating essential skills and knowledge, enabling the early detection of acute exacerbations, which may ultimately reduce hospitalization rates while enhancing prognosis and quality of life.¹⁴ Yet, the current landscape of publicly available COPD applications is characterized by heterogeneity in designs, functionalities, and quality levels, largely devoid of robust evidence supporting their clinical utility.¹⁵ Furthermore, critical hurdles regarding technology acceptance, data security, sustained engagement, and seamless integration into existing healthcare pathways demand urgent resolution.^17,18

Given this context, refining COPD self-management strategies necessitates breaking free from traditional molds to embrace innovative approaches. First, the deployment of home monitoring and early warning systems: by leveraging wearable devices, home medical equipment, and mobile app technologies, clinicians can continuously gather physiological parameters, symptom data, and behavioral indicators within the patient’s domestic environment. Algorithmic models can then analyze this data to detect early signals of acute exacerbations, effectively providing early warnings before a crisis unfolds.¹⁹ Second, adopting the philosophy of “minimal resource rehabilitation”: in settings where resources are scarce or regular medical support is absent, the focus shifts to utilizing simple, highly accessible tools—such as basic breathing exercises, community support groups, and low-cost monitoring devices—to maintain and improve functional status.²⁰ By deeply integrating and systematically consolidating these innovative directions, it is expected to overcome the current practical bottlenecks.

This review aims to comprehensively summarize the current status and challenges of self-management in patients with COPD, focusing on optimization strategies that integrate home monitoring and early warning systems, and “minimal resource rehabilitation” approaches within the management framework. By examining the synergistic application of evidence-based medicine, behavioral change theory, and digital health technologies, this study provides a theoretical basis and practical guidance for establishing a more resilient, patient-centered management ecosystem.

This article presents a narrative review. To ensure comprehensiveness and balance, we conducted a literature retrieval. The databases searched included PubMed, Web of Science, and the Cochrane Library. Search terms covered key concepts such as “COPD self-management”, “pulmonary rehabilitation”, “telemonitoring”, and “digital health”, which were combined using Boolean logic (AND/OR) and limited to title and abstract fields. The publication timeframe was from January 2020 to March 2026. Inclusion criteria comprised peer-reviewed, English-language literature focusing on COPD self-management interventions. Exclusion criteria were: editorials and case reports. Study selection was based on data relevance, quality (assessed via journal impact and methodological rigor), and timeliness; this process was conducted independently by two researchers who resolved discrepancies through consensus.

Core Content and Theoretical Basis of Self-Management in COPD Patients

Definition and Theoretical Framework of Self-Management

Self-management in COPD patients refers to the series of daily activities and decision-making processes undertaken by patients to maintain health and cope with the disease, primarily aimed at enhancing their sense of self-efficacy.²¹ There are multiple conceptualizations of COPD self-management, among which a medical activity-centered perspective is dominant, while alternative frameworks emphasize patients’ lived experiences.²² Effective self-management interventions are typically grounded in frameworks such as social cognitive theory, self-efficacy theory, and the Chronic Disease Self-Management Program (CDSMP), which emphasize the interplay of knowledge, skills, confidence, and social support in behavior change.²³ These theoretical frameworks collectively form the foundation for designing self-management interventions to equip patients with the capacity to manage their disease through strategies such as education, goal setting, problem-solving, and action planning.²³

Core Components and Practical Skills

For patients with COPD, the core components of self-management are multidimensional and are fundamental to symptom control and prevention of acute exacerbations. Key aspects include the following (Table 1):

Table 1.

Summary Table of Core Components and Practical Skills for COPD Self-Management

Core Component	Practical Skills	Key Findings/Challenges
Precise Medication Management	Correct use of inhaler devices; understanding pharmacology and side effects; long-term treatment adherence24	Studies found up to 94.3% of patients fail to use inhalers correctly25
Symptom Monitoring& Coping Strategies	Accurate identification of subtle changes in dyspnea, cough, and sputum; application of breathing techniques and energy conservation to relieve discomfort26	Improved symptom control directly empowers self-management ability26
Early Warning & Action for Exacerbations	Reliance on a personalized “action plan”; initiation of rescue medication, contacting healthcare providers, or seeking emergency help when warning signs appear	Ensure patients recognize the warning signs and the response protocols27
Home Monitoring & Home-Based Pulmonary Rehabilitation	Portable devices were utilized to monitor oxygen saturation and respiratory rate, integrated with threshold-based alert systems to provide remote guidance for home-based pulmonary rehabilitation.	Aims to improve accessibility and continuity of interventions
Long-Term Maintenance of Healthy Lifestyle	Continuous smoking cessation support; proper nutrition and weight management; moderate physical activity and pulmonary rehabilitation; psychosocial adaptation28	Finnish studies demonstrate that mental health and stress management are often neglected,28 whereas the COPD guidelines emphasize comprehensive interventions29
Comorbidity Management	Identification and management of common comorbidities (eg, cardiovascular disease, anxiety, and depression), medication management proficiency; coordination of lifestyle modifications; routine follow-up and screening	COPD guidelines recommend the “treatable traits” model to develop self-management plans tailored to each patient’s individual symptom profile and comorbidities29

The above core elements collectively constitute the practical skill system for self-management in COPD patients, necessitating that healthcare professionals help patients comprehensively master and apply them through systematic education, technical support, and resource guidance.

Implementation Frameworks and Therapeutic Approaches for COPD Self-Management Support

Conventional Frameworks: The Constraints of Rigid Education and Routine Follow-Up

The established paradigm for supporting self-management in COPD relies predominantly on formalized patient instruction and scheduled clinical reviews. Typically delivered by a multidisciplinary team—encompassing respiratory specialists, nursing staff, physical therapists, and dietitians—hospital or community-based health education seeks to systematically impart disease literacy and managerial competencies.³⁰ Yet, the reach of this approach is often curtailed, particularly for individuals grappling with mobility impairments or those residing in isolated regions. Furthermore, multicenter comparative analyses have uncovered marked disparities across medical facilities regarding the frequency, duration, and thematic emphasis of educational interventions, underscoring the inherent challenges in achieving standardized deployment.³⁰ Another cornerstone model merges personalized counseling with periodic outpatient visits, prioritizing the collaborative establishment of management objectives alongside the iterative refinement of action plans. However, the efficacy of this strategy is inextricably linked to both the availability of healthcare resources and the patient’s intrinsic motivation.³¹ Qualitative studies reveal that medical staff frequently narrow their follow-up focus to pharmacotherapy and smoking cessation, offering limited guidance on lifestyle pillars such as physical activity and nutrition, while largely overlooking critical psychosocial facets like mental well-being and stress mitigation.^28,31 This imbalance in content coverage hampers the holistic reinforcement of self-management regimens, indicating that traditional structured education must evolve to embrace a more comprehensive scope—one that integrates home monitoring, early warning systems, and access to home-based rehabilitation resources to confront the multifaceted burdens of the disease.³²

Innovation Support Model: Convergence of Digital Technology and Remote Monitoring Interventions

The evolution of digital tools has radically reshaped the landscape of self-management, merging technology with remote monitoring interventions to stretch the horizons of what intervention can achieve. At the heart of this shift lie internet and mobile applications, which serve as vital conduits for care. These digital platforms offer a range of functionalities—from logging symptoms and prompting medication adherence to delivering educational visuals, guiding breathing exercises, and synthesizing home monitoring data.³³ By facilitating real-time oversight, early alerts, and immediate feedback, they significantly boost the ease, engagement, and proactive nature of care.³⁴ Meanwhile, remote monitoring interventions leverage wearable sensors to track vital signs like oxygen saturation, heart rate, and physical activity, pairing these metrics with video consultations. This allows clinicians to evaluate patient status and intervene early from afar, a lifeline particularly for those hindered by mobility issues or geographic isolation.²³ Such frameworks can further extend to oversee and assess home-based pulmonary rehabilitation outcomes. Furthermore, AI and big data analytics represent the forefront of supportive technologies. These technologies forecast acute exacerbation risks, tailor management advice, and refine intervention strategies.³⁴ A mixed-methods study grounded in self-determination theory revealed that interventions like pulmonary rehabilitation and digital tools (eg, PocketMedic) bolster patient motivation and experience by fulfilling core psychological needs, including competence and relatedness. This lays the groundwork for theory-driven, personalized technological interventions that also reinforce self-management skills within resource-constrained settings.³⁵ Together, these emerging models chart a course toward a future defined by personalization, accessibility, data-centricity, and adaptability, offering a path to transcend the resource dependencies and access barriers inherent in traditional approaches.

However, the application of the aforementioned innovative models in real-world settings still faces many challenges. Table 2 the main benefits and limitations of digital/remote monitoring interventions in COPD self-management across four dimensions:

Table 2.

Comprehensive Assessment Form of Digital/Remote Monitoring Interventions in COPD Self-Management

Dimension	Main Benefits	Main Limitations	Evidence Level
Symptom Monitoring and Acute Exacerbation Early Warning	Digital tools identify early signals, reducing hospitalization rates by 20–30% (especially in severe patients)8,36–38	Approximately 30–40% of elderly patients cannot use independently;39 15% of data lost due to technical issues;33 health inequalities worsen in low-education/low-income groups;40 Average warning response time >4 hours41	RCT: Supported by multiple studies, but with small sample sizes and short follow-up, evidence strength limited; Systematic review/Meta-analysis: Moderate evidence for reducing hospitalization rates, but no significant impact on mortality
Treatment Compliance and Self-Efficacy	Improved compliance; self-efficacy scores increase by 15–20%; personalized goals and incentives enhance behavioral change8,37	Long-term compliance drops to 40–50% after 6 months;42 no difference from control group when compliance <60%8	RCT: High heterogeneity; combined education outperforms single technology (moderate evidence)
Medical Resources and Costs	Emergency visits reduced by 18%; hospital stay shortened by 2–3 days; total costs decrease by 10–20%36,38,43	Cost-effectiveness evidence is limited not only in quantity but also by its heavy dependence on specific geographic regions and healthcare systems, which limits the generalizability of its conclusions;41 Inadequate insurance reimbursement, often requiring out-of-pocket payment	Real-world studies: Effects lower than RCT (hospitalization rate reduction 10% vs 20%), but show cost-effectiveness (saving $5000–10,000 per QALY), lower evidence level
Quality of Life and Mental State	St. George’s Respiratory Questionnaire scores improve by 5–10 points; anxiety scores decrease by 15%44–46	Although short-term benefits were evident, they were followed by a long-term decline;47 additionally, the study suffered from a limited sample size37,38	RCT: Short-term improvement supported, but follow-up mostly <6 months; Meta-analysis: Moderate impact on hospitalization rates (moderate evidence strength)

Key Factors Influencing the Effectiveness of Self-Management in Patients with COPD

Patient Individual Factors

Correct Disease Cognition and Health Literacy Form the Foundation of Self-Management

Research indicates that a clear understanding of the etiology, disease course, and treatment goals of COPD is a prerequisite for patients to effectively participate in self-management.²¹ Lack of health literacy not only affects patients’ ability to acquire and understand health information but also weakens their capacity to communicate effectively with healthcare teams and make informed health decisions.¹⁹

Patients’ Self-Efficacy and Psychological State Profoundly Influence Their Management Behaviors

Patients with high self-efficacy are more likely to adhere to management plans. Specifically, self-efficacy can stimulate self-care, positive thinking, and participation in enjoyable activities, synergistically alleviating core symptoms such as dyspnea, low mood, fatigue, and feelings of loss of control.⁴⁸ Conversely, comorbid anxiety and depression significantly weaken patients’ motivation and ability to participate in management.⁴⁹ Psychological resilience, serving as a resource for stress resistance, exhibits a significant positive correlation with self-management behaviors; this reciprocal relationship builds patients’ internal strength to cope with disease challenges.⁵⁰

Sociodemographic Factors Indirectly Shape Self-Management Effectiveness by Influencing Resource Access and Execution Capability

Age, education level, economic status, and the strength of social support networks (especially family support) significantly influence patients’ ability to understand and execute complex management plans.⁵¹ The role of family support is particularly crucial. However, family caregivers, while motivating patients for self-management, often feel neglected by healthcare professionals due to a lack of knowledge about disease progression and information on available medical resources, bearing a heavy burden.⁵² This directly weakens patients’ ability to execute management plans at home (such as medication adherence and breathing exercises). Economic status affects patients’ access to services like lung rehabilitation and telemedicine, which may require out-of-pocket expenses. Differences in sociodemographic factors lead to different potential categories of self-management behaviors, and identifying these categories helps provide more targeted support.⁵³

Medical System

Continuity and Coordination of Medical Services

The fragmentation between primary care and specialized nursing, as well as interruptions in follow-up visits, can severely undermine the continuous support for patients’ self-management. Efficient continuous nursing should cover three dimensions: longitudinal, informational, and managerial, ensuring that patients receive seamless services across different stages of the disease and between different medical institutions.⁵⁴

Competence and Mindset of Care Providers

The extent to which healthcare professionals possess sufficient specialized skills, communication skills, time, and willingness to provide self-management education is a decisive factor in the quality of self-management education interventions, thereby directly influencing patient acceptance and compliance. However, the current situation is concerning. Overall, due to the lack of specialized skills among healthcare professionals in the early identification of this disease, many patients with chronic obstructive pulmonary disease remain undiagnosed.⁵⁵ Furthermore, although healthcare professionals regularly educate patients on clinical aspects such as medication treatment, smoking cessation, and exercise, psychosocial aspects crucial for coping with the disease, such as mental health, stress management, and fatigue, are often overlooked.²⁸ Healthcare professionals’ understanding of the concept of self-management also varies, primarily falling into two categories: a medically-centered perspective and one grounded in patients’ life experiences. The opposition between these two perspectives is not conducive to establishing a collaborative relationship.²² Healthcare professionals need to possess the ability to assess patients’ health literacy needs, communicate effectively, and provide personalized education.⁵⁶

Evaluation of the Effectiveness and Existing Challenges of COPD Self-Management Interventions

Outcome Measures and Evidence Base

Numerous randomized controlled trials and meta-analyses have shown that effective self-management interventions can significantly improve various clinical outcomes in patients with COPD.⁸ In terms of clinical outcomes, one of the core objectives of self-management interventions is to reduce exacerbation events and their associated healthcare resource utilization. A multicenter comparative study indicated that, despite differences in the content and frequency of interventions across institutions, effective self-management education can still favorably alter patients’ healthcare-seeking behaviors.³⁰ Specifically, enhancing patients’ ability to recognize and manage symptoms early can reduce unnecessary emergency department visits.³⁰ Dyspnea, as a core symptom of COPD, is often assessed using the modified Medical Research Council Dyspnea Scale; furthermore, self-management strategies such as exercise and improving self-care efficacy have been proven to be significantly associated with the alleviation of dyspnea symptoms.⁴⁸

Regarding patient-reported outcomes, self-management interventions yield significant improvements in patients’ health-related quality of life and mental health. Research indicates that, based on self-determination theory, meeting patients’ basic psychological needs for autonomy, competence, and relatedness can promote their self-management behaviors, thereby improving quality of life.³⁵ Additionally, self-management behaviors are significantly positively correlated with psychological resilience, with better self-management abilities associated with higher psychological resilience scores, which helps patients better cope with the psychological challenges posed by the disease.⁵⁰

From a health economics perspective, although initial resources may be required for patient education and support, effective self-management programs are cost-effective in the long run.⁸ The mechanism lies in reducing COPD exacerbations and related hospitalizations, thereby lowering overall healthcare expenditures.³⁰ Although direct health economics indicators (such as cost-effectiveness ratios) are rarely discussed in detail in the existing literature, reducing exacerbations and hospitalization rates constitutes the core pathway to lowering medical costs. Achieving health behavior change through structured, personalized multi-component interventions has been proven to be an important component of the long-term care system for chronic obstructive pulmonary disease (COPD), with benefits including improving patients’ quality of life and reducing the frequency of exacerbations and the use of acute medical resources.²³ Therefore, investing in self-management education and support is considered a public health strategy with long-term economic benefits.

Main Challenges and Limitations in Current Practice

Although COPD self-management interventions have shown positive effects, they still face numerous challenges and limitations in current practice.

① Heterogeneity and lack of standardization in interventions: There are significant differences in the content, intensity, duration, and frequency of education among self-management interventions implemented by different studies and clinical institutions, lacking a recognized “gold standard” protocol.³⁰ A multicenter comparative study revealed significant differences in the educational content provided and specific interventions among different medical institutions.³⁰ This heterogeneity leads to inconsistent intervention effects and hinders the comparability and generalizability across different studies or clinical programs.

② Difficulty in maintaining long-term patient adherence and behavior: Many patients’ self-management behaviors gradually weaken after the structured intervention program ends. For example, a study on adherence to COPD exacerbation action plans found that only 26.2% of patients could initiate optimal self-treatment (such as self-administration of prednisolone) during the early stages of exacerbation (≤2 days), with a considerable number of patients experiencing treatment delays, no treatment, or inappropriate medication use during non-exacerbation periods.²⁷ Studies have pointed out that patients with more severe baseline dyspnea and comorbid heart disease may have lower adherence to exacerbation action plans, suggesting the need for more targeted support.²⁷ Furthermore, a qualitative analysis of patients with moderate COPD found that the level of self-management is closely related to patients’ personal resources (such as knowledge, acceptance of the disease). Many patients avoid activities due to a lack of knowledge about tolerable physical activity levels, which hinders the long-term maintenance of healthy behaviors.³¹

③ The rise of digital health solutions has brought about “digital divide” and equity issues: Although digital therapeutics and remote management provide new tools for COPD self-management, they may exclude elderly patients who are unfamiliar with technology, economically disadvantaged, or have lower education levels, thereby exacerbating health inequalities.²³ A study on online COPD self-management programs found that patients with lower education levels and limited prior knowledge benefited the most from digital programs, yet they are precisely the group that faces the greatest difficulties in digital access and usage.³¹ If digital health interventions become mainstream and some patients cannot access them equally, existing health disparities may further widen.

④ Methodological limitations and potential biases in effect evaluation: Many studies face issues such as difficulties in implementing blinding and suboptimal control group designs (eg, unclear content of usual care), which may overestimate intervention effects.³⁰ For example, in observational studies, if appropriate statistical methods (such as marginal structural models) are not used to address time-dependent prescribing biases, it may affect the accuracy of evaluating the long-term effectiveness of corresponding treatments.⁵⁷ Additionally, patient feedback and satisfaction with interventions may be influenced by factors such as social desirability, which need to be considered in evaluation designs.

Optimization Strategies

Innovating Self-Management Education Models and Content

Developing Personalized and Stratified Education Programs

For self-management education in COPD patients, a shift from standardized models to highly individualized programs is necessary. This transition should be based on a comprehensive assessment of the patient’s condition. Factors such as disease severity, cognitive function, health literacy, stage of behavior change, and level of social support collectively influence the patient’s response to educational interventions and tangible outcomes. For example, one study used the Patient Activation Measure (PAM-13) to assess the readiness for self-management in COPD patients. The results showed that patients with higher activation levels (PAM levels 3–4) significantly increased their daily step count by an average of 680±253 steps after receiving a single group education session focused on physical activity. In contrast, patients with lower activation levels (PAM levels 1–2) experienced a decrease in steps (−596±42 steps).⁵⁸ This finding clearly indicates that the development of education programs should be based on pre-intervention assessments to determine the patient’s readiness, thereby providing intervention content and intensity that match their activation level. Additionally, a patient’s self-management ability is significantly influenced by factors such as education level, average monthly income, social support, and degree of dyspnea.⁵⁹ Therefore, effective personalized education plans should integrate comprehensive assessments of the patient’s socioeconomic status, psychosocial support network, and clinical symptom burden, ensuring that education not only imparts knowledge but also stimulates and supports the patient’s intrinsic motivation and behavior change.

Implementing a stratified management strategy is key to optimizing resource allocation and improving intervention efficiency.⁸ For high-risk patients with limited self-management capacity, such as those with frequent exacerbations, multiple comorbidities, or low health literacy, more intensive, multidisciplinary team-based support is required. For example, early screening using tools like the Malnutrition Universal Screening Tool (MUST) or Mini Nutritional Assessment (MNA) combined with personalized nutritional counseling has been shown to be an effective multidisciplinary intervention strategy for COPD patients with malnutrition.⁶⁰ For patients with severe disease and high symptom burden, multidisciplinary collaborative support incorporating palliative care concepts is crucial, covering symptom control, quality of life improvement, and caregiver support.⁶¹ On the other hand, for patients in stable condition with strong self-management abilities, the focus should be on providing maintenance support and remote monitoring. Digital health technologies show great potential in such stratified management. For instance, real-time air quality warning interventions based on the WeChat platform have been shown to be more effective than conventional pollution knowledge education in reducing the risk of exacerbations, with an Internal Rate of Return (IRR) of 0.607, and improving symptom scores in stable COPD patients.⁶² Telerehabilitation, web-based education platforms, and virtual reality technologies also open new avenues for providing accessible, customizable maintenance support.^63,64 The core of this stratified strategy rests on precise risk stratification, thereby prioritizing limited professional medical resources (such as face-to-face support from multidisciplinary teams) for patients with the most urgent needs, while utilizing scalable digital tools to provide continuous, convenient self-management support for patients with greater self-management capacity. This approach aims to maximize overall care efficiency and effectiveness.

Strengthening Content Centered on Skill Training and Behavior Change

Self-management education for COPD is undergoing a profound shift from mere knowledge transmission to practice-oriented skill reinforcement training. Research indicates that successful self-management interventions must go beyond information delivery and focus on mastering core management skills through repeated practice.⁶⁵ Self-management support for COPD should strive to transform complex treatment regimens into daily operational skills that patients can practice repeatedly until they internalize them.

Integrating behavior change techniques is essential for ensuring the long-term sustainment and incorporation of self-management skills into daily routines. Self-efficacy, as a core cognitive concept in behavior change, is crucial for chronic disease management. Digital tools and telemedicine offer new avenues for this, helping patients sustain healthy behaviors by providing continuous tools and skill support.²³ Gamification design, as an emerging strategy, can significantly enhance patients’ initiative and enjoyment in engaging in self-management activities like exercise by embedding goal setting, progress feedback, and reward mechanisms into interactive contexts.⁶⁶ Additionally, interventions integrating peer support show potential in enhancing self-efficacy and personal empowerment in chronic disease management.⁶⁷ Ultimately, by combining skill training with behavior change techniques, self-management interventions can better help patients organically integrate disease management into their lives, completing the transition from “cognition” to “practice”, thereby improving quality of life and reducing acute exacerbation events.^38,65

Optimization and Deep Integration of Digital Health Technologies with Remote Support, Embedded Home Monitoring and Early Warning Systems

① Personalized intervention linked to home monitoring and early warning systems: Intervention plans are developed based on patient characteristics such as age, disease severity, and cultural background. For elderly COPD patients, the convenience and accessibility of technology use are primary considerations. Research indicates that elderly patients have a high acceptance of remote monitoring technology but prefer using simple devices, such as reporting oxygen saturation values via an app or website.⁶⁸ Therefore, intervention plans should incorporate voice navigation, large-font interfaces, and simplified operational procedures to lower the technical barrier. For younger populations, gamification incentives can be introduced. By employing dynamic adjustment algorithms (eg, acute exacerbation risk prediction models), the system optimizes the frequency and content of feedback based on real-time monitoring data, thereby enhancing intervention relevance and adherence. Studies show that by integrating real-time monitoring data (eg, heart rate, oxygen saturation, activity level) with historical medical records, machine learning models can effectively predict COPD acute exacerbation events.^69,70 The combination of personalized goal setting (eg, daily steps, medication adherence) with patient preferences, coupled with the automatic adjustment of goal thresholds via intelligent algorithms, can strengthen self-efficacy and promote long-term engagement.⁴⁸ Simultaneously, home monitoring and early warning systems can automatically trigger graded alerts based on this, enabling early risk identification.

② Multimodal technology integration and home monitoring and early warning network construction: Integrate wearable devices (eg, activity tracking smart bands, pulse oximeters for oxygen monitoring), mobile applications (symptom diaries, health education modules), and telemedicine platforms (video consultations, data sharing) to form a comprehensive support system.⁷¹ Through automatic synchronization and report generation functions of electronic health records, the burden on healthcare workers is reduced, and clinical collaboration efficiency is improved. AI technologies (eg, Natural Language Processing for parsing symptom descriptions, Machine-learning for predicting acute exacerbation events) not only enhance warning accuracy and feedback personalization but also serve as the core engine of the home monitoring and early warning systems, enabling real-time capture and intelligent interpretation of abnormal physiological signals.

③ Patient education support and capacity building for home monitoring and early warning systems: Conduct digital literacy training (covering device operation guides, data interpretation methods) and provide continuous technical support (eg, 24-hour service hotline) to effectively reduce technical barriers. Establish social support platforms (including patient forums, peer support groups) and implement regular telephone follow-ups to enhance treatment adherence and strengthen psychological support. These measures aim to foster patients’ intrinsic motivation and ensure the sustainable operation of the project; more critically, through the dissemination of information on home monitoring and early warning systems and simulation exercises involving their use, patients and their families can master emergency response skills, thereby establishing a robust home safety net.

④ Deep clinical integration and closed-loop home monitoring and early warning management: The development of standardized data interfaces (eg, HL7 FHIR) promotes the seamless integration of digital tools with electronic health records, thereby improving clinical utility.⁷² Form a remote monitoring response team (including nurses, respiratory therapists, doctors, etc.) to ensure timely handling of warning information and minimize the risk of intervention delays.⁷³ On this basis, home monitoring and early warning systems act as front-end sensing nodes, forming a closed loop with the back-end clinical response mechanism to facilitate an efficient workflow from home monitoring to professional intervention.

Optimization Strategy Three: Building a Hospital-Community/Home Continuous Care Model Based on Minimal Resource Rehabilitation

Establishing standardized discharge planning and referral processes is crucial for ensuring a smooth transition of patients with COPD from the hospital to home, which directly impacts the continuity of self-management plans and the effective transmission of key information. Research indicates that service disconnections within the current care system are one of the major barriers to continuity of care. A qualitative study of patients receiving home non-invasive ventilation found that the “fragmentation” of care services hindered discussions on advance care planning; both patients and healthcare professionals recognized that limited collaboration and communication between different service providers severely compromised care continuity.⁷⁴ Consequently, this disconnection prevents key information, such as action plans, from being effectively communicated to community healthcare workers post-discharge, resulting in interruptions to self-management support. Another phenomenological study focusing on family caregivers of patients discharged after an acute exacerbation of COPD revealed similar issues, with caregivers commonly feeling “abandoned by medical professional institutions”, highlighting the failure in the transition from hospital to home care.⁷⁵ To address this challenge, research advocates for the development of clear inter-agency protocols and processes to resolve communication bottlenecks.⁷⁴ The essence of standardized discharge planning lies in achieving seamless information coupling. For example, a qualitative study on remote palliative care found that cross-sector collaboration is a cornerstone in building patient safety, and efficient communication mechanisms can significantly enhance care coherence.⁷⁶ During the COVID-19 pandemic, the implementation of proactive home monitoring systems demonstrated that secure data platforms can facilitate information exchange and collection among patients, service providers, and regional health management authorities, thereby ensuring a closed loop of care continuity.⁷⁷ Therefore, reconstructing discharge and referral processes based on standardized protocols and digital platforms is the fundamental prerequisite for ensuring the continuous transmission of core self-management information, such as action plans.

Strengthening the effectiveness of COPD management in community-based primary healthcare institutions is the cornerstone for ensuring that patients can access continuous self-management support nearby. This requires systematic capacity-building training for community medical staff and the establishment of a robust specialist-community linkage network. Empirical data show a significant positive correlation between the improvement of primary healthcare capabilities and patient prognosis. A Norwegian registry study indicated that among various elements of outpatient care, the continuity of general practitioner care (ie, the sustained therapeutic relationship between patients and a fixed doctor) is closely associated with a 15% reduction in COPD hospitalizations the following year.⁷⁸ Additionally, the intensity of interaction among healthcare providers at different levels (such as referral efficiency and communication depth) is also linked to a 7% decrease in hospitalization rates, further emphasizing the necessity of strengthening inter-institutional collaboration.⁷⁸ To upgrade community management capabilities, training strategies need to focus on practical skills. For example, research on family caregivers of COPD patients emphasizes that medical professionals should receive specialized training to provide timely clinical interventions and psychological support to caregivers during potential exacerbations.⁷⁵ Meanwhile, innovative models integrating specialist care and community services show great potential. An accelerated experiential co-design project successfully developed a care model that embeds home exercise training into the “hospital-home” care continuum. This model emphasizes the integrity of the service chain and deep dialogue among various stakeholders, and is implemented by professionals with dual qualifications in home exercise guidance and routine home care.⁷⁹ Telemedicine technology provides a powerful lever for strengthening such linkages and capacity building. A systematic review of virtual ward models indicates that comprehensive models encompassing home assessments and case management are significantly associated with reduced emergency department visits and reduced time to readmission.⁸⁰ Furthermore, a user-centered design study developed a prototype for a “Telehealth Education: Leveraging e-Transitional Care” televisit intervention, aimed at supporting discharge transitions through medication reconciliation and inhaler education. Its workflow design ensures deep integration with routine discharge care transition processes, thereby optimizing care continuity.⁸¹ In summary, by empowering community medical teams through training and leveraging telemedicine technology and collaborative mechanisms to weave a tight specialist-community network, the management capabilities of community-based primary care for COPD can be effectively enhanced, providing patients with accessible and continuous self-management support.

Future Research Directions and Policy Recommendations

Research Areas Requiring Urgent In-Depth Exploration

Although self-management measures for COPD have shown significant potential in improving patients’ quality of life and reducing hospitalisation, current research still has several critical knowledge gaps that urgently require further exploration.

More systematically integrating behavior change theories into intervention program design is key to improving effectiveness. Existing evidence indicates that self-management programs that include continuous doctor-patient interaction and are implemented by professionals proficient in behavior change techniques (BCTs) are more effective in stimulating patients’ intrinsic motivation, enhancing their confidence and capabilities, thereby empowering patients to proactively adopt healthy behaviors and master disease management skills. However, existing studies are generally limited by inadequate reporting details, inconsistent standards, and a lack of transparency regarding the specific components of interventions and the BCTs used. This hinders a comprehensive understanding of which combination of BCTs is most effective for patient subgroups with distinct characteristics. Although the effectiveness of self-management plans is recognized, more research is needed to clarify how their specific effective components (such as initiation methods, educational content, support and monitoring means) affect patients’ skill acquisition and quality of life improvement.⁸² Future research should focus on identifying and validating the optimal combinations of behavior change techniques for different patient characteristics (such as disease stage, psychological state) to promote the personalized development of intervention programs.

Conducting long-term cost-effectiveness evaluations for optimization strategies is crucial, as this directly relates to the rational allocation of health resources and the sustainable promotion of interventions. New strategies such as digital health interventions and multidisciplinary team support are receiving increasing attention. A value of information analysis study showed that the potential research value of online self-management interventions for COPD patients could reach hundreds of millions of dollars, highlighting the necessity of conducting high-quality economic evaluations to reduce decision-making uncertainty.⁸³ However, currently available COPD self-management applications perform unevenly in terms of clinical evidence support, safety, and overall quality, generally lacking solid evidence to support their clinical application. Furthermore, a meta-analysis on the effectiveness of mobile health applications revealed conflicting findings within the existing evidence; coupled with high heterogeneity in outcome measures across trials, this precludes the derivation of consistent conclusions.⁸⁴ Therefore, there is an urgent need to conduct well-designed long-term studies to evaluate the cost-effectiveness of these digital interventions and new service models in reducing healthcare resource consumption and improving patient clinical outcomes, thereby providing reliable evidence-based support for health policymakers.^85,86

Focusing on health equity research is fundamental to ensuring that all COPD patients can benefit from self-management. Significant disparities exist in the accessibility, acceptability, and effectiveness of existing interventions across diverse populations. Studies have shown that patients with lower health literacy face difficulties in understanding text-based self-management plans, necessitating the development of adaptive strategies such as illustrated materials.⁸⁷ Additionally, patients with low socioeconomic status, advanced maternal age, or multiple comorbidities, as well as individuals from ethnic minority groups, encounter more severe self-management barriers, including insufficient knowledge, financial pressure, lack of family support, and poor accessibility to healthcare services.⁸⁸ A systematic review highlighted that the role of health literacy in the development of self-management skills among COPD patients remains unclear, and more research is needed to explore educational methods suitable for different health literacy levels and cultural contexts.¹² Future research must be dedicated to designing accessible, acceptable, and effective self-management support programs for these vulnerable groups, such as through training community health workers, integrating culturally adaptive elements, or leveraging technology to overcome geographical and economic barriers.⁸⁹ Only by focusing on health equity can the goal of universal access to COPD self-management support be truly achieved.

Although digital health technologies have opened new avenues for COPD self-management, their full potential has yet to be realized. Future research should shift towards personalized support systems centered on precision medicine. Specifically, the following three directions warrant in-depth exploration: (1) Multi-omics-based risk stratification and biomarker-guided intervention: Future interventions should not rely solely on symptom questionnaires or single physiological indicators but should integrate genomics, proteomics, and metabolomics data to identify distinct disease subtypes (eg, eosinophilic vs neutrophilic phenotypes). For instance, blood eosinophil count can serve as a dynamic biomarker for predicting acute exacerbation risk and evaluating the efficacy of corticosteroids. By establishing polygenic risk scores or proteomic profiles, the system can prospectively stratify exacerbation-prone populations, thereby triggering more targeted preventive interventions earlier.⁹⁰ (2) Digital Phenotyping: Transitioning from Passive Monitoring to Active Sensing. Through wearable devices and smartphones, digital phenotypes can be constructed—mapping patients’ real-world status in real time via passively collected activity patterns, sleep rhythms, voice analysis, and actively reported symptom logs. Future systems should be capable of capturing subtle pre-exacerbation changes (eg, declining daily step trends, increased nocturnal oxygen fluctuations) and linking them to clinical phenotypes and biomarkers. This not only enhances the accuracy of early warnings but also provides dynamic decision-making support for personalized interventions. (3) AI-driven multi-omics and multimodal data fusion: A mature system should seamlessly integrate multi-omics data (genetic markers, inflammatory indicators), continuous sensor streams (heart rate, blood oxygen, activity levels), electronic health records, and environmental exposure data through artificial intelligence. Such integration will generate patient-specific dynamic risk scores and adaptive treatment plans. For example, when an AI model simultaneously detects warning signals from biomarkers (eg, rising inflammatory factors) and shifts in digital phenotypes (eg, sustained decline in activity), the system can automatically adjust medication reminder intensity, push educational content recommending limited outdoor exposure, and remotely notify the response team. Employing explainable AI and federated learning frameworks can help enhance clinical trust and ensure data privacy.⁹¹

Suggestions for Macro Policies and System-Level Support

Incorporating structured COPD self-management support services into the national basic public health services or chronic disease management programs is a key policy pathway to improve overall care quality. Research indicates that clear policy incentives and payment mechanisms are critical prerequisites for the effective implementation of services. Health policymakers should establish performance-based payment models to incentivize medical institutions to provide high-quality, structured self-management support, rather than merely offering basic medical services. Integrating such services into the national chronic disease management framework helps ensure stable resource investment and standardized service implementation. This systemic integration can transform self-management support from an optional add-on service into an indispensable core component of the standard COPD care pathway, thereby benefiting a broader patient population.

Promoting the interoperability of medical information systems to ensure the secure sharing of patient health information is the data foundation for building a continuous self-management support system. A study conducted in China revealed significant disparities in the diagnosis, therapy, and management of COPD among different levels of medical institutions under the tiered diagnosis and treatment system, with primary care facilities having much lower rates of pulmonary function testing and standardized inhalation therapy use compared to tertiary hospitals.⁹² These disparities are largely due to the lack of seamless data flow between different institutions, often necessitating the repetition of diagnostic and therapeutic processes. A unified health information platform should be established to ensure that patient information, such as pulmonary function data, medication records, and history of acute exacerbations, can be securely and promptly shared between primary care institutions and higher-level hospitals. Furthermore, interoperable information systems can support the application of AI-based early screening tools at the grassroots level. For example, the effective promotion of AI-assisted COPD screening deployed in primary care institutions in China relies on high-quality data support and cross-institutional data collaboration.⁹³ At the policy level, efforts should be made to break down information silos, establish unified data standards and interface specifications, and lay a solid foundation for data-driven continuous self-management.

Encouraging cross-sectoral collaboration, involving social security, civil affairs, and other departments, to provide comprehensive support for severe or impoverished COPD patients is a systemic solution to alleviate their self-management burden. COPD is not only a respiratory disease but also affects patients’ psychological, social, and economic well-being. Studies indicate that patients with COPD frequently experience significant anxiety and depression; however, these mental health comorbidities are often underdiagnosed and undertreated due to resource constraints and limited awareness.⁹⁴ Among patients with severe disease and those facing socioeconomic disadvantage, economic pressures, social isolation, and disparities in access to care are particularly acute. Addressing these issues requires efforts beyond the health sector alone. Policymakers must facilitate synergistic collaboration between the health sector and key agencies, including social security, civil affairs, and disability federations. This cross-sectoral collaboration model is particularly important in low- and middle-income countries, where resources for comprehensive support services are especially scarce, requiring coordinated efforts in national policies, professional training, and healthcare infrastructure investment.⁹⁵ Establishing a robust social safety net can effectively reduce the economic and psychosocial barriers patients face in self-management, thereby advancing health equity.

Conclusion

Given the complexity of COPD as a chronic disease, its long-term management has gradually evolved from a traditional medical-led model to a self-management model that emphasizes patient-centeredness and active participation. Effective self-management is a core strategy for improving the quality of life of COPD patients, reducing acute exacerbations, and lowering the medical burden. Its successful implementation relies on a comprehensive system encompassing patient education, skills training, ongoing support, and adaptive behavioral changes.

From an expert perspective, the development of the COPD self-management field shows a clear trajectory from “standardized programs” to “personalized programs”. This shift reflects a move from “merely establishing efficacy” to rigorously investigating “how it is most effective and sustainable for whom, and under what circumstances”. The key to integrating insights and findings from different studies lies in recognizing that COPD self-management is not a single intervention but a dynamic, contextualized process. On one hand, the fundamental role of core components such as structured education and action plans must be affirmed; on the other hand, it must be acknowledged that their effectiveness is modulated by multiple factors including patients’ cognitive levels, social support, comorbidities, and healthcare accessibility. Digital health tools demonstrate revolutionary potential in enhancing accessibility and interactivity.

COPD self-management has entered a new phase characterized by the deep integration of evidence into practice. By integrating personalized medicine, digital health, and implementation science, and adhering to the principle of equity, it is expected that a more resilient, inclusive, and sustainable COPD management ecosystem can be built in the future, ultimately empowering each patient to achieve better long-term health outcomes.

Disclosure

The authors report no conflicts of interest in this work.