Introduction: Selective main stem intubation for treatment of unilateral lung overdistension in preterm infants is known for many decades. Here, we report selective left main bronchial intubation for surfactant replacement therapy with inhomogenous lung disease and pulmonary air leak syndrome. Case: A baby boy was born at 38+2 weeks’ gestation by cesaerian section. Birth weight was 3,360 g and Apgar scores were 8 and 8 at 1 and 5 minutes. Tachypnea(respiratory rate 70-80/min), chest retraction, and grunting were developed after birth. In spite of oxygen therapy (10L/min by oxygen hood), oxygen saturation was 80% and his respiratory distress was aggravated. Chest X-ray revealed the ground grass appearance. He was intubated and conventional ventilator therapy was started. Inspired oxygen fraction of 100% was needed. There was no abnormality on echocardiography. The diagnosis was respiratory distress syndrome on full term newborn. Surfactant replacement therapy was done as routine practice and his respiratory symptoms was dramatically improved. After 6 hours, there was abrupt respiratory deterioration and right-sided pneumothorax developed that required drainage with a chest tube. A chest radiography revealed worsening pneumothorax and hyperinflation of the right lung, still-noted ground grass appearance of the left lung. We suggested the possibility that there was uneven instillation of surfactant at surfactant replacement therapy. Despite of chest tubing, conventional ventilator care, and left-side up position, his respiratory distress was aggravated. Failure of conventional therapies and worsening respiratory function prompted selective left bronchial intubation for surfactant replacement therapy of the left lung. Selective blind intubation and surfactant instillation of the left main stem bronchus has been successful on day 4. After this, his clinical condition improved and subsequent chest radiographs showed adequate expansion of both lungs. Three days later the ventilator and chest tube was removed. Conclusion: Selective bronchial intubation and surfactant replacement therapy was used successfully as rescue treatment to heterogenous lung disease with pulmonary air leak syndrome.