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Lung diseases such as lung cancer, chronic obstructive pulmonary disease(COPD), and pulmonary fibrosis(PF) urgently require new treatment strategies due to their complex pathological mechanisms and the limitations of existing therapies. Traditional Chinese medicine(TCM) has a long history and proven efficacy in treating lung diseases, characterized by a "multi-component, multi-target, and multi-pathway" treatment approach, but its molecular mechanisms still require systematic analysis. Exosomes, as key mediators of intercellular communication, participate in disease progression and serve as specific biomarkers by delivering proteins, nucleic acids, and metabolites. Tumor-derived exosomes drive the formation of the pre-metastatic microenvironment and immune suppression in lung cancer, while inflammatory cell-derived exosomes exacerbate airway damage in COPD. Additionally, fibroblast-derived exosomes aberrantly activate the Wnt pathway, promoting the progression of PF. Exosome proteomics provides a crucial breakthrough for elucidating the mechanisms of TCM in treating lung diseases, revealing the synergistic intervention of TCM on inflammation and tumor metabolism through high-throughput identification of key proteins regulated by TCM. Furthermore, dynamic changes in exosome proteins can quantitatively assess drug efficacy and resistance mechanisms. Technologically, 4D proteomics combined with single-vesicle membrane protein analysis can accurately analyze the heterogeneity of TCM-induced exosome subpopulations, advancing the precise validation of the "components-targets-efficacy" treatment approach in TCM and accelerating its clinical translation. Looking ahead, integrating multi-omics analysis will systematically reveal the molecular networks through which TCM formulas regulate disease targets via exosome proteins, providing comprehensive solutions for the diagnosis and treatment of lung cancer, COPD, and PF, from mechanism elucidation to clinical translation.