OBJECTIVES: To examine the effectiveness of chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). DATA SOURCE: CINAHL, MEDLINE, Embase, Cochrane, Expanded Academic Index, Clinical Evidence, PEDro, Pubmed, Web of Knowledge and Proquest were searched from the earliest available time to September 2007, using the key elements of COPD, acute exacerbation and chest physiotherapy interventions. REVIEW METHODS: To be included, trials had to investigate patients during admission to hospital with an acute exacerbation of COPD, and to evaluate at least one physiotherapy intervention. Two reviewers independently applied the inclusion criteria, and assessed trial quality using the PEDro scale. Results were expressed as standardised mean differences and analysed qualitatively with a best-evidence synthesis. RESULTS: Thirteen trials were identified. There was moderate evidence that intermittent positive pressure ventilation and positive expiratory pressure were effective in improving sputum expectoration. In addition, there was moderate evidence that walking programmes led to benefits in arterial blood gases, lung function, dyspnoea and quality of life. No evidence was found supporting the use of any other chest physiotherapy techniques to change lung function, arterial blood gases, perceived level of dyspnoea or quality of life. CONCLUSIONS: Chest physiotherapy techniques such as intermittent positive pressure ventilation and positive expiratory pressure may benefit patients with COPD requiring assistance with sputum clearance, while walking programmes may have wider benefits for patients admitted with an exacerbation of COPD. Chest physiotherapy techniques other than percussion are safe for administration to this patient population.