The objective of this study was to determine whether flexible fiberoptic bronchoscopy could be performed safely and as effectively without premedication while using a standardized topical anesthetic. Twenty-one patients were included in a randomized double-blind study. Nine procedures performed without premedication were compared with 12 procedures performed with premedication (atropine and midazolam). Measures of efficacy included patient tolerance, sedative effect, overall impression, complications, and requirements for additional anesthetics or sedation. Patients given premedications found the procedure more tolerable overall (p = 0.043) and less unpleasant during tracheal intubation (p = 0.02) and distal airway surveillance (p = 0.009), and were more willing to accept a repeat procedure if indicated (100%). Bronchoscopists found no differences between the two groups with regard to sedative effect and level of tolerance. Additional use of sedatives was not required, and no complications were identified in either group. These results support the continued role of premedication use in flexible fiberoptic bronchoscopy, although the risks and benefits should be individualized prior to each procedure.