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Dutch,
Bad bad case!! Premies don't give you much time. Bradycardia in kiddies still makes the hair on my neck stand up! You are right about the nasal ETT as a nasal airway now and probably whistling in the graveyard at best. Nearly all neo-natal intubations are awake with no relaxants, the tongue on a neo-nate is very strong and the oral mass adds to your nightmare. With the left tracheal displacement, I have to wonder what else is going on that I can't see.
Two things I would probably try. First as adal suggested, needle cricothyrotomy using as large an IV intercath you are comfortable using; maybe an 18ga. Once in the airway pull the needle and leave the cath pointing caudad. I believe a 4.0 mm ET adapter will fit snugly into the hub of the intercath. Jet ventilate. This is not the total answer but can buy some time. I have done this in the ER with success on adults, CO2 buildup will become a problem but it can provide oxygenation in the short trem. In that small window of time, your surgeon will be nearer, and get Pedi Bronch stuff together. Mobilize the nearest surgeon to do a trach if needed.
Second would be for a more perm solution such as pedi bronch slide inside a pedi ETT. I think this is the best answer for ETT placement and a better look at the subglottic airway. Something has pushed the trachea to the left and it would be important to RO and subglottic airway mass!
Last resort, emergent trach.
Soft tissue studies of the neck to RO other masses. I'm willing to bet there may be another mass in the area of the glottis. I'd like to hear how this turned out. Bad Bad juju here.
RF 1
ps: It is possible to pull off a retrograde intubation using an epidural needle ( cricothyrotomy) with bevel oriented cephlad. Pass an epidural cath up into the oropharynx and grab it with a pair of clamps. Thread ETT over cath and down the cath through the cords. This is not easy and only a remote possibility. I doubt you will have enough room in the oropharynx given the mass your are dealing with. Kiddie may not have enough time for you to struggle through attempt; but it is possible.
rf
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