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Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

No dyspneic patient should be given a general
anesthetic; because any patient dyspneic enough to need a tracheotomy
for dyspnea is depending largely upon the action of the accessory
respiratory muscles. When this action is stopped by beginning
unconsciousness, respiration ceases. If the trachea is not immediately
opened, artificial respiration instituted, and oxygen insufflated, the
patient dies on the table. Skin infiltration along the line of
incision with a very weak cocaine solution (1/10 of 1 per cent),
apothesine (2 per cent), novocaine, Schleich's fluid or other local
anesthetic, suffices to render the operation painless. The deeper
structures have little sensation and do not require infiltration. It
has been advocated that an interannular injection of cocaine solution
with a hypodermic syringe be done just prior to incision of the
trachea for the purpose of preventing cough after the incision of the
trachea and the insertion of the cannula. It would seem, however, that
this introduces the risk of aspiration pneumonia and pulmonary
abscess, by permitting the aspiration and clotting of blood in small
bronchi, followed by subsequent breaking down of the clots. As the
author has so often said, The cough reflex is the watch dog of the
lungs, and if not drugged asleep by local or general anesthesia can
safely be relied upon to prevent all possibility of the blood or the
pus which nearly always is present in acute or chronic conditions
calling for tracheotomy, being aspirated into the deeper air-passages.
Cocaine in any form, by any method, and in any dosage, is dangerous in
very young children.

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