Background: Extremely premature neonates can have neonatal respiratory distress syndrome. Anesthetic challenges can result, especially during rigid bronchoscopy requiring maintenance of spontaneous ventilation.Case: 1-day old 560 g female, 23-weeks and 6 days gestation was born with labored breathing and intubated at birth. Four attempts, including one with video-laryngoscopy and visualization of the endotracheal tube going through the vocal cords failed to detect end tidal carbon dioxide (EtCO2). She was extubated onto bilevel positive pressure and transferred for urgent rigid bronchoscopy under anesthesia to rule out tracheoesophageal fistula. Intraoperatively, lack of EtCO2 for over 1 min after 2.5 mm ETT placement over a rigid bronchoscope was noted and overcome using sustained high peak inspiratory pressures. Conclusions Lack of preoperative surfactant administration in extremely premature neonates may lead to significant atelectasis with inability to detect EtCO2 after intubation.