Objective <p>The aim of this study was to compare the efficacy and safety of remimazolam with those of propofol in older patients undergoing fiberoptic bronchoscopy with preserved spontaneous breathing.</p> Methods <p>Sixty older patients were randomly and equally divided into a remimazolam group (group R) and a propofol group (group P). Both groups received 0.15&#xa0;µg/kg of sufentanil for analgesia. Group R received an initial dose of 0.2&#xa0;mg/kg remimazolam and was injected with a maintenance dose of 1&#xa0;mg/kg/h. Group P received an initial dose of 2&#xa0;mg/kg propofol and was injected with a maintenance dose of 4&#xa0;mg/kg/h. The primary evaluation indicators were the success rate of sedation and the incidence of hypotension. The secondary evaluation indicators were respiratory depression, hypertension, tachycardia, bradycardia, awakening time, quality of recovery-15 (QOR-15) score, patient satisfaction, physician satisfaction, and adverse events.</p> Results <p>Success rates of sedation were similar between group R (96.7%) and group P (100%). The incidence of hypotension in group R was lower than that in group P (2/30 vs. 10/30, <i>p</i> = 0.01). Respiratory depression was lower in group R than in group P (3/30 vs. 10/30, <i>p</i> = 0.03). Fewer patients reported injection pain in group R (0/30 vs. 7/30, <i>p</i> = 0.01). There were no significant differences in hypertension, tachycardia, bradycardia, awakening time, QoR-15 score, patient satisfaction, physician satisfaction, or adverse events between the two groups.</p> Conclusions <p>Remimazolam has a high sedation success rate for painless fiberoptic bronchoscopy in older patients, and the incidence of hypotension and respiratory depression is lower than that of propofol. Remimazolam may be a better choice for sedation during painless fiberoptic bronchoscopy in older patients with preserved spontaneous breathing.</p> Trial registration <p>ChiCTR2300069041; 6/3/2023.</p>