The Expert Consensus on the Implementation and Management of Multidisciplinary Team Care for Chronic Obstructive Pulmonary Disease (2026 Edition), developed by the expert panel and the Chronic Obstructive Pulmonary Disease Assembly of the Chinese Thoracic Society, has been published in the National Medical Journal of China. Grounded in clinical practice in China, the consensus provides 11 recommendations covering the objectives, organization, workflow, target population, documentation, quality assessment, and teleconsultation requirements of multidisciplinary team (MDT) care. It offers healthcare institutions a systematic and implementable framework for standardized multidisciplinary management of chronic obstructive pulmonary disease (COPD).
Comprehensive COPD management requires multidisciplinary collaboration
COPD is clinically heterogeneous. In addition to airflow limitation, dyspnea, and recurrent exacerbations, patients frequently have pulmonary and extrapulmonary comorbidities, including cardiovascular disease, lung cancer, diabetes, osteoporosis, sarcopenia, anxiety and depression, and sleep-related breathing disorders. The consensus notes that more than 85% of patients with COPD have at least one chronic comorbidity. These conditions increase the risks of exacerbation, hospitalization, and death, while complicating polypharmacy, perioperative care, rehabilitation, and long-term follow-up. A conventional single-specialty model cannot fully address these needs, making a respiratory-led MDT approach clinically important.
The consensus defines the overall objective of COPD MDT care as the delivery of patient-centered, multidisciplinary collaboration that integrates cross-specialty resources, supports one-stop decision-making across the entire care pathway, and achieves optimal comprehensive treatment of COPD and its comorbidities. MDT care is not limited to difficult diagnoses; it should also support treatment optimization, assessment of drug-drug interactions, non-pharmacological interventions, perioperative risk management, rehabilitation, nutritional and psychological support, and longitudinal follow-up.
A COPD “1+N” team structure and standardized workflow
The consensus recommends the COPD “1+N” structure. A respiratory physician serves as the leading expert and establishes the team. Core members include specialists in cardiovascular medicine, thoracic surgery, rehabilitation medicine, nutrition, and clinical pharmacy. Depending on the scenario, the extended team may include experts in oncology, psychiatry or neurology, endocrinology, anesthesiology, radiology, laboratory medicine, otorhinolaryngology, orthopedics, pathology, and traditional Chinese medicine. An MDT coordinator should be appointed to organize meetings and manage documentation.
In-person MDT meetings are preferred. When geography or resources constrain the face-to-face participation, a hybrid in-person and remote model may be used. Meetings should be held regularly, with a rapid-response mechanism for critically ill patients. The standardized pathway comprises application, case screening, and data preparation before the meeting; case presentation, multidisciplinary discussion, decision-making, and formal documentation during the meeting; and communication with patients and families, implementation, and follow-up after the meeting. The leading expert synthesizes the recommendations and finalizes the individualized plan, which is then implemented by the relevant specialties.
Comprehensive clinical information should be prepared in advance. This includes demographic and medical history, symptoms and exacerbation history, smoking and occupational exposures, physical examination findings, laboratory results, chest CT, pre- and post-bronchodilator spirometry and diffusing capacity, and, when indicated, cardiopulmonary exercise testing and the 6-minute walk test. Assessments relevant to comorbidities, current treatment for COPD and accompanying conditions, response to treatment, and the preferences of patients and families should also be available.
Priority populations for MDT management
COPD MDT care is primarily intended for patients in whom diagnosis or treatment is difficult, disease is complex or severe, multisystem comorbidities are present, multiple pharmacological and non-pharmacological interventions are needed, standard therapy cannot be accepted, or surgery is required. Priority groups include patients with severe or very severe COPD, recurrent exacerbations, or respiratory failure; candidates for lung resection, surgical lung-volume reduction, or lung transplantation; patients requiring coordinated management of multisystem disease; those unable to follow a standard regimen; and patients with COPD who require surgery for another condition.
The consensus further identifies seven common clinical settings in which MDT care should be considered: COPD with cardiovascular disease, lung cancer, diabetes, sarcopenia, anxiety or depression, sleep-related breathing disorders, and perioperative management. Team composition should reflect the principal clinical problem. Differentiating cardiac from pulmonary dyspnea, managing pulmonary hypertension, or addressing a cardiovascular emergency requires close respiratory-cardiology collaboration. Evaluation of a pulmonary lesion, selection of lung-cancer treatment, and management of immune therapy-related pneumonitis may require respiratory medicine, thoracic surgery, oncology, radiology, pathology, rehabilitation, and clinical pharmacy. For surgical patients with moderate-to-severe ventilatory impairment, frequent exacerbations, or respiratory failure, MDT management should span the preoperative, intraoperative, and postoperative periods.
Shared decision-making, complete documentation, and continuous quality improvement
MDT discussion should establish an accurate diagnosis and assessment of COPD and its comorbidities and produce a treatment plan, alternative options, and a follow-up schedule. Shared decision-making is a core principle: physicians lead the clinical process while patients participate in decisions. Available options, expected benefits, potential risks, and limitations should be fully explained, and informed choice should be respected and documented.
Documentation should cover the entire sequence of application, discussion, decision, implementation, and follow-up. Required records include the MDT application and approval materials, meeting notes, a comprehensive management recommendation, and records of implementation and follow-up. The MDT coordinator organizes these materials, while the institution requesting the consultation retains the medical records in accordance with applicable requirements.
Quality management should be embedded throughout the pathway and should address objectives, clinical processes, institutional governance, and data and document management. Suggested indicators include completeness of MDT records, implementation of recommendations, patient outcomes, complications or adverse events, adherence, and satisfaction. The operating system should be continuously improved across four dimensions: institutional design, process management, implementation outcomes, and patient satisfaction. The lead expert should periodically review performance and organize professional education so that evidence and relevant guidelines remain current.
Tele-MDT can extend access to high-quality specialist care
For complex or difficult cases, severe exacerbations, and high-risk perioperative patients, tele-MDT consultation may be requested from a higher-level hospital or regional COPD center when local expertise is insufficient or the patient is too unstable to transfer. A remote MDT platform should include a data system that supports secure transmission, real-time recording, and multi-party sharing of medical information, together with reliable audio and video communication. It should comply with healthcare information standards and relevant laws and regulations and should protect the collection, processing, storage, and transmission of patient information, ensuring data integrity, traceability, and privacy.
From single-disease care to comprehensive COPD management
This consensus provides the first systematic implementation and management framework for COPD MDT care in China. It addresses team formation, case selection, information preparation, meeting procedures, shared decision-making, implementation, follow-up, documentation, quality assessment, and teleconsultation. Its 11 recommendations emphasize both the quality of clinical decisions and the institutional mechanisms needed for sustained improvement, allowing healthcare institutions at different levels to develop standardized MDT services suited to their resources.
The publication of the consensus is expected to advance COPD care from a model centered on a single respiratory diagnosis toward comprehensive management that also considers comorbidities, functional status, and patient goals. Respiratory-led collaboration and end-to-end quality management can improve the scientific rigor and feasibility of decision-making for complex COPD, facilitate implementation of individualized care, and ultimately improve long-term patient outcomes.
Publication Details
Expert Panel of the Expert Consensus on the Implementation and Management of Multidisciplinary Team Care for Chronic Obstructive Pulmonary Disease; Chronic Obstructive Pulmonary Disease Assembly, Chinese Thoracic Society. Expert consensus on the implementation and management of multidisciplinary team care for chronic obstructive pulmonary disease (2026 edition). National Medical Journal of China. 2026;106(24):2455-2468. doi:10.3760/cma.j.cn112137-20260111-00121.
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