随着慢性疾病（简称慢病）负担加重，呼吸机依赖人群持续扩大，传统康复管理面临数据割裂、路径不连贯及依从性差等问题。本文围绕慢病呼吸机依赖患者的院内外一体化管理需求，探讨智慧化呼吸康复平台的建设思路与实现路径，结合多场景应用，分析其在优化康复流程、提升管理连续性中的作用；并对数据互联互通、标准规范、智慧化应用深度及医患数字化适配等问题进行讨论，以期为相关实践提供参考。

With the increasing burden of chronic diseases, the population dependent on mechanical ventilation continues to grow, while traditional rehabilitation management faces challenges such as fragmented data, discontinuous care pathways, and poor adherence. Focusing on the need for integrated in-hospital and out-of-hospital management for patients with chronic disease who are dependent on mechanical ventilation, this article discusses the development and implementation of an intelligent respiratory rehabilitation platform. Based on its application in multiple scenarios, its role in optimizing rehabilitation pathways and improving continuity of care is analyzed. Current challenges, including data interoperability, standardization, the depth of intelligent application, and digital adaptation of both healthcare professionals and patients, are also discussed, in order to provide a reference for related practice.