Relationship Between Navigation Success, Diagnostic Accuracy, and Ventilation Strategy: Retrospective Chart Review of 224 Consecutive Navigational Bronchoscopic Procedures Performed Under General Anesthesia

<b>Background</b>: Navigational bronchoscopy (NB) enables precise sampling of peripheral and central pulmonary nodules using shape-sensing or electromagnetic guidance. A major challenge is anesthesia-induced atelectasis, which alters lung anatomy, reduces registration accuracy, and is known to lower diagnostic accuracy. To counteract this, ventilatory protocols such as the Ventilatory Strategy to Prevent Atelectasis (VESPA) and the Lung Navigation Ventilation Protocol (LNVP) have been recommended. Their adoption and clinical impact, however, remain uncertain. <b>Methods</b>: We conducted a retrospective review of 224 consecutive NB procedures performed under general anesthesia at a single academic medical center (January 2020-August 2024). Demographic, anesthetic, and ventilatory data were extracted from electronic records. Outcomes included navigational success (ability to reach the lesion) and diagnostic accuracy (concordance between bronchoscopic diagnosis and final clinical diagnosis after follow-up). Ventilatory practices were compared with published VESPA and LNVP recommendations. <b>Results</b>: Navigational success, defined as successful advancement of the bronchoscope to the target lesion with tissue acquisition, was achieved in 89.2% of cases. Overall diagnostic accuracy, defined as concordance between bronchoscopic diagnosis and final clinical diagnosis after follow-up, was 81.7%. Ventilatory management consistently diverged from recommended protocols. Most patients were ventilated with FiO₂ > 0.6, PEEP in the range of 7-10 cm H₂O, and tidal volumes of 300-500 mL. The only recommended maneuver systematically applied was recruitment immediately after intubation. Despite widespread deviation from both VESPA and LNVP, diagnostic performance remained favorable relative to published benchmarks. No major anesthesia-related complications occurred. <b>Conclusions</b>: In this retrospective series, navigational success comparable to published studies that adapted strict ventilation protocols was achieved with also comparable diagnostic accuracy without strict adherence to predefined ventilatory strategies. Recruitment maneuvers may represent the most influential component of current protocols, but institutional factors such as procedural expertise and case volume likely contributed to outcomes. Prospective studies are warranted to determine whether standardized ventilatory protocols are necessary for optimizing NB performance.