There really aren't any "right or wrong" ways to manage this or any airway; the only hard and fast rule when it comes to any very difficult airway is to avoid taking away respiratory drive and airway reflexes unless absolutely necessary. I would not attempt to intubate this patient in the field unless it really came down to a "she needs a tube right now or she is going to die" situation. I'm glad that everyone seems to be on the same page with that. So everything we discuss about managing this airway is done with that important caveat in mind.
The first question that I want to answer when I assess an airway is always "can I mask this patient"? If I can mask a patient, then I can attempt intubation safely no matter how difficult it might be to actually pass a tube. Part of the Pierre-Robin sequence is a glossoptosis that can make masking difficult, and this patient looks to me like a potentially very difficult mask. A nasopharyngeal airway may or may not help.
Prone positioning is typically used in sleeping infants and small children whose PR has not yet been corrected. However, any airway obstruction that occurs in the supine position, whether from OSA, a mediastinal mass, an anterior subglottic mass, or a glossoptosis
may be relieved by prone positioning. Would you transport a patient with a difficult airway prone? Potentially, sure. There are risks involved obviously, but as long as you have a plan to quickly turn the patient supine if necessary, I think it could be a really appropriate part of your plan of care.
I'm really glad someone mentioned retrograde intubation (
@Akulahawk). Assuming the patient is breathing adequately and you do not have flexible fiberoptic available but you do have the drugs and the skill to blunt airway reflexes without abolishing respiratory drive, retrograde is probably the best solution that I can think of. However, if she was breathing adequately I probably wouldn't be messing with her airway in the field in the first place, so it might not be applicable here.
Blind nasotracheal intubation relies heavily on normal anatomy, so it would be hard in this patient. It might be worth a try, especially if it means not paralyzing, but I think it'd be a long shot and remember, we are only doing this because she has to be tubed
now. So probably not the best option.
VL may or may not be a better option than DL. I think it depends on which specific device you have and how skilled you are with either approach. I would use whichever you are more experienced and confident with.
The exact approach you use is obviously going to depend on the specific circumstances. There's probably little to be lost by trying an LMA first. Assuming that isn't feasible or doesn't work for whatever reason, I would advocate an approach where we view this airway management operation as a "rapid-sequence cricothyrotomy with a brief pause to attempt intubation", rather than as the normal "rapid-sequence intubation with cric as the backup plan". This means assessing the neck, marking the landmarks, prepare the cric kit, and prepping the neck, while the other operator (hopefully there are two) is going through the normal pre-RSI preparation. Doing everything necessary to make the first attempt the best attempt, someone pushes the drugs and the intubator makes his attempt with the neck cutter assisting. As soon as Sp02 starts to fall or the airway starts to get even a little bloody the laryngoscope blade comes out and the intubator becomes the assistant to the neck-cutter, who does his thing.
