Respiratory health in a changing environment: environment-adaptive therapies and revised dosing strategies

INTRODUCTION: Chronic airway diseases, such as asthma and COPD, are major contributors to global morbidity and the healthcare burden. Due to their heterogeneity and sensitivity to environmental factors, including air pollution, tobacco smoke, and occupational exposures, they are critical models for examining how the environment shapes disease biology and treatment response. AREAS COVERED: This expert narrative review integrates mechanistic, clinical, and epidemiological evidence on the impact of environmental exposures on the biology of airway disease and therapeutic outcomes. A structured literature search was performed, prioritizing mechanistic studies, large cohorts, randomized trials, and high-quality reviews relevant to asthma and COPD endotypes, phenotypes, and environment-adaptive therapies. The evidence indicates that environmental exposures modulate inflammatory pathways, oxidative stress, and drug responsiveness. These exposures often account for variability in clinical outcomes and apparent treatment resistance. EXPERT OPINION: Environmental exposures should be recognized as core biological modifiers that directly impact therapeutic efficacy, dosing requirements, and safety. Incorporating a systematic approach to environmental assessment into precision respiratory medicine allows for environment-adaptive therapies, optimizes pharmacological interventions, and reduces the risk of overtreatment. Future research and clinical protocols should integrate exposure metrics to personalize therapy, improve symptom control, and enhance long-term outcomes for patients with asthma and COPD.