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Background : The initial treatment of a primary spontaneous pneumothorax (PSP) is controversial. Guidelines of the British Thoracic Society recommend simple aspiration for all PSP requiring intervention. The placement of chest tubes is only advocated for patients who fail simple aspiration. However, the American College of Chest Physicians Delphi Consensus Statement found simple aspiration to be rarely appropriate in the management of PSP. Aims : To compare simple aspiration with chest-tube drainage in the initial management of PSP. Methods : Meta-analysis of randomized controlled trials (RCTs). Outcome measures : Reductions in duration of hospital stay, recurrence rate and pain or dyspnoea score were classified as benefits, whereas reductions in successful events were classified as risks. Data collection and analysis : For dichotomous data, the relative risk (RR) and 95% confidence intervals were calculated. For continuous data, weighted mean differences (WMD) were used. Results : Three RCTs were identified with a combined total of 194 patients. Simple aspiration was associated with shorter hospitalization (WMD −1.30 days [−2.20 to −0.39]). The results for success rate could not be combined because of differences in outcome definitions. However, a pooled result for "success at 1 week or more" showed no significant difference between either intervention (RR 0.86 [0.67, 1.11]). Results of recurrence at 1 year were also not significantly different (RR 0.73 [0.39–1.38]). Different reporting systems for pain scores meant that data could not be pooled. Only one trial reported dyspnoea scores. Conclusion : RCT evidence in this field is limited, and the total sample size is too small to make any firm conclusion. On the basis of current available evidence, simple aspiration is advantageous in the initial management of PSP because of shorter hospitalization. There is no significant difference in recurrence at 1 year using either modality, and the efficacy data are inconclusive.