<p>Narrow-band imaging (NBI) enhances mucosal and vascular contrast during bronchoscopy and may support the detection of malignant airway lesions, although its specific diagnostic role in routine practice is still being defined. This single-centre retrospective observational study evaluated the relationship between NBI vascular patterns and histological diagnosis in 49 patients undergoing bronchoscopy for suspected lung cancer. Vascular patterns were classified as normal, dotted, abrupt-ending, or tortuous; dotted, abrupt-ending, and tortuous patterns were collectively considered pathological. Malignancy was confirmed in 34 patients (69.4%). Pathological vascular patterns were observed in 28 malignant cases and in three non-malignant cases, whereas normal patterns were present in six malignant and 12 non-malignant cases, corresponding to a sensitivity of 82.4%, specificity of 80.0%, positive predictive value of 90.3%, and negative predictive value of 66.7%. Pathological patterns were significantly associated with malignant histology (<i>p</i> &lt; 0.001). Some numerical differences in the distribution of individual pathological patterns across histological subtypes were considered exploratory only. In conclusion, pathological NBI vascular patterns were significantly associated with malignant disease and demonstrated good diagnostic performance as an adjunct to white-light bronchoscopy. NBI should be regarded as a complementary tool for lesion assessment and biopsy guidance, while histopathological confirmation remains essential.</p>