Acute lung injury (ALI) is a critical clinical disease caused by direct factors (inhalation injury, gastroesophageal reflux, etc.) or indirect factors (including infection, sepsis, burn, shock, trauma, acute pancreatitis, fat embolism, drug overdose, etc.). ALI is characterized mainly by diffuse interstitial and alveolar edema caused by an uncontrolled inflammatory response and damage to the alveoli-capillary barrier and has very high morbidity and mortality rates. Currently, there is no effective treatment strategy other than mechanical ventilation, fluid management or other supportive treatments. Exosomes are nanovesicle-like vesicles with double-membrane structures detached from the cell membrane or secreted by cells. These vesicles can be used as drug carriers because of their unique biological properties, such as anti-inflammatory, anti-apoptotic, pro-cell growth and immunomodulatory functions, and have been applied in the treatment of ALI in recent years. In this study, the mechanism and pathophysiological characteristics of ALI were first systematically described. The different cellular sources and characteristics of exosomes are summarized, and their functions and value as drug carriers in the treatment of ALI are discussed, as are the challenges that may be faced in the treatment of ALI with exosomes.