Can Veterinary Hospitals Safely Reuse Endotracheal Tubes?

By Steve Mehler, DVM, DACVS

What the Evidence Actually Shows

Endotracheal tubes are routinely reused in many veterinary hospitals. A tube is removed after anesthesia, washed, soaked in a disinfectant, dried and placed back into circulation. If it looks clean and the cuff still inflates, it may appear ready for another patient.

But looking clean is not the same as being microbiologically safe—and eliminating recoverable bacteria is not the same as proving that a single-use tube can be safely reused.

The veterinary literature on this subject remains surprisingly limited. A recent canine study identified an intensive multistep protocol capable of producing culture-negative tubes under controlled conditions. Earlier studies, however, found that commonly used cleaning methods frequently left viable bacteria behind. There is also evidence that repeated processing may damage the cuff even when a tube looks normal.

So, what can we legitimately conclude from the available evidence?

First, cleaning, disinfection and sterilization are not interchangeable

These terms describe different processes:

• Cleaning physically removes mucus, blood, saliva and other organic material. It must generally occur before a disinfectant can reliably contact the surface.

• Disinfection inactivates many or most pathogenic microorganisms, with effectiveness depending on the product, concentration, exposure time and level of disinfection achieved.

• Sterilization destroys all viable microorganisms, including bacterial spores.

• Culture-negative means that nothing grew under the specific sampling and laboratory conditions used. It does not prove that every organism, biofilm component, endotoxin or chemical residue has been eliminated.

That distinction is central to interpreting the newest study.

The most promising canine study: the ESPAWD protocol

In 2026, Ascione and colleagues evaluated 100 endotracheal tubes used during routine anesthesia in dogs. The researchers studied an approach called ESPAWD, representing a sequence involving an enzymatic solution, peracetic acid, water rinsing and drying.

The complete process involved:

1. A 30-minute enzymatic-detergent soak

2. A 30-minute peracetic-acid soak

3. A one-minute tap-water rinse

4. Twenty-four hours of air drying

The individual steps were also evaluated separately. Water alone failed to disinfect most tubes. Enzymatic solution alone failed in every tube tested. Peracetic acid performed much better, but some treated tubes still produced microbial growth. In contrast, all evaluable tubes completing the entire ESPAWD sequence were culture-negative.

This is an important and encouraging finding. It demonstrates that a carefully controlled multistep protocol can eliminate recoverable bacterial and fungal growth from previously used tubes under the study conditions.

However, the study did not demonstrate that the tubes were clinically safe to reuse.

The tubes were processed only once and were not subsequently placed into another dog. The investigators did not evaluate airway inflammation, postoperative respiratory infection, chemical residues, repeated-cycle cuff integrity, pilot-valve performance or the maximum number of times a tube could safely undergo processing. Tubes with visible contamination, regurgitation, airway disease, oral surgery or apparent damage were also excluded.

The correct interpretation is that ESPAWD is a promising disinfection protocol requiring additional clinical, toxicologic and repeated-cycle validation. Describing the study as proof that single-use tubes are safely reusable would go beyond its findings.

Common cleaning methods frequently fail

A 2023 study by Marquis and colleagues evaluated 100 tubes collected from anesthetized dogs. The tubes were assigned to one of four cleaning protocols commonly reported in veterinary practice.

Cleaning protocol	Tubes with no post-cleaning bacterial growth
Water scrub	15/25 (60%)
Detergent scrub	14/25 (56%)
Detergent plus chlorhexidine	20/25 (80%)
Detergent plus bleach	17/25 (68%)

No statistically significant difference was identified among the protocols, and none was consistently effective.

The practical message is straightforward: washing a tube with water or detergent—or adding chlorhexidine or bleach—cannot be assumed to make that tube microbiologically safe. The accompanying survey also confirmed that reuse was common, although the cleaning approaches being used were not supported by strong evidence.

Routine cultures may underestimate surviving organisms

Crawford and Weese approached the question from another direction in 2015. They experimentally contaminated sterile endotracheal tubes with Streptococcus equi subsp. zooepidemicus and Bordetella bronchiseptica, two clinically important canine respiratory pathogens.

The tubes were treated with accelerated hydrogen peroxide, chlorhexidine, triclosan-containing soap or water. Some treatments initially appeared successful when assessed by direct culture. However, viable organisms were subsequently recovered using enrichment culture, a more sensitive technique capable of detecting smaller surviving populations.

None of the evaluated treatments consistently achieved high-level disinfection.

This study exposes an important limitation in interpreting culture-negative results: failure to grow an organism does not necessarily prove that none remains. Results depend on how the tube was sampled, which area was sampled, the culture conditions and the sensitivity of the detection method.

Microbiological safety is only half of the question

Even a perfectly disinfected tube would not be safe to reuse if processing weakened the cuff, inflation line, pilot balloon, valve, connector or tube wall.

In a 2024 case report, Shin and Jang described cuff rupture during anesthesia in two dogs. Both endotracheal tubes had undergone repeated ethylene-oxide sterilization. The authors believed that repeated sterilization, excessive cuff inflation and positive-pressure ventilation likely contributed to the failures.

A two-case report cannot determine the incidence of cuff rupture or establish that sterilization was the sole cause. Nevertheless, it provides clinically relevant evidence that repeated processing may affect tube integrity. A tube can look normal during inspection and still fail after placement, particularly when the cuff is exposed to inflation pressure and positive-pressure ventilation.

This is why microbiological testing alone cannot validate reuse. A complete reprocessing claim must address both decontamination and device performance over multiple cycles.

Could contaminated airway equipment contribute to hospital transmission?

During an outbreak involving blaNDM-5 carbapenem-resistant Escherichia coli, Lavigne and colleagues evaluated risk factors for organism acquisition within a veterinary hospital. Exposure to the anesthesia service, surgery service and endotracheal intubation was associated with increased odds of acquisition.

This study did not prove that reused tubes transmitted the organism. Endotracheal intubation may simply have identified patients exposed to a broader collection of equipment, surfaces, personnel and hospital locations.

Still, the findings reinforce a broader point: anesthesia equipment can participate in nosocomial transmission pathways. Contamination of airway equipment should not be dismissed as a purely theoretical concern.

What do human studies add?

Two human studies are frequently discussed when considering whether single-use tubes could be reprocessed.

Yoon and colleagues experimentally contaminated endotracheal-tube cuffs with Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa, then processed them using ethylene oxide or glutaraldehyde. No growth of the test organisms was recovered after sterilization. However, repeated ethylene-oxide treatment softened the cuffs, while glutaraldehyde exposure also altered cuff properties under some conditions. Even this comparatively supportive study acknowledged that processing could compromise physical integrity.

Yauger and colleagues later examined the durability and disinfection of single-use tubes exposed to several commonly available compounds. Cuff function did not change significantly under the measured conditions, but microbiological results were mixed and possible experimental contamination complicated interpretation. The authors presented reuse as a potential last-resort response during mass-casualty conditions when replacement supplies were unavailable—not as validation for everyday practice.

Neither study can establish safety in dogs. Canine tubes may be handled, selected, inflated and reused differently, and neither human investigation evaluated clinical veterinary outcomes.

What has never been demonstrated in dogs?

No identified canine study has directly compared new tubes with reprocessed tubes placed into subsequent patients. Important unanswered questions include:

• Does reuse increase postoperative coughing, tracheal inflammation or respiratory infection?

• Can detergent, chlorhexidine, bleach or peracetic-acid residues remain inside the tube or cuff system?

• Is mature biofilm reliably removed from the entire internal lumen?

• What happens to cuff compliance and leak pressure after repeated processing cycles?

• How long do the pilot valve, inflation line and connector remain dependable?

• How many times, if any, can a tube be safely reprocessed?

• Can a protocol remain effective when tubes contain visible mucus, blood or gastric material?

• Will a time-intensive protocol perform as reliably under real-world hospital conditions as it does in a controlled study?

These are not minor gaps. A safe-reuse claim requires evidence of microbiological effectiveness, chemical safety, mechanical reliability and acceptable clinical outcomes—all at the same time.

The defensible conclusion

Current evidence does not establish that routine reuse of manufacturer-labeled single-use endotracheal tubes is safe in dogs.

The ESPAWD study is meaningful because it demonstrates that an intensive multistep protocol can produce culture-negative tubes under restricted conditions. It deserves additional investigation. But successful cultures alone do not establish that a tube remains chemically safe, mechanically dependable or clinically noninferior to a new tube after repeated processing.

Meanwhile, commonly used cleaning protocols frequently leave recoverable bacteria, and repeated sterilization has been implicated in cuff failure during canine anesthesia.

Veterinary hospitals that reuse endotracheal tubes should therefore recognize that this practice is not currently supported by a fully validated canine reprocessing standard. At a minimum, hospitals should follow manufacturer labeling, remove damaged or visibly contaminated tubes from service and avoid assuming that washing, soaking or a negative culture automatically makes a single-use device safely reusable.

The science has moved forward—but it has not yet crossed the line from promising disinfection to proven safe reuse.

References

1. Ascione F, Radu IL, Di Nola S, et al. Efficacy of an endotracheal tube disinfection protocol and the impact of its steps on tubes collected from dogs anaesthetized for routine clinical procedures. Veterinary Anaesthesia and Analgesia. 2026;53:101157.

2. Marquis CR, Gull T, Dodam JR, Bukoski A. Comparison of four endotracheal tube cleaning protocols in anesthetized dogs. Journal of the American Veterinary Medical Association. 2023;261:336–341.

3. Crawford S, Weese JS. Efficacy of endotracheal tube disinfection strategies for elimination of Streptococcus zooepidemicus and Bordetella bronchiseptica. Journal of the American Veterinary Medical Association. 2015;247:1033–1036.

4. Shin CW, Jang M. Endotracheal tube cuff rupture during anesthesia in 2 dogs. Canadian Veterinary Journal. 2024;65:363–366.

5. Lavigne SH, Cole SD, Daidone C, Rankin SC. Risk factors for the acquisition of a blaNDM-5 carbapenem-resistant Escherichia coli in a veterinary hospital. Journal of the American Animal Hospital Association. 2021;57:101–105.

6. Yoon SZ, Jeon YS, Kim YC, et al. The safety of reused endotracheal tubes sterilized according to Centers for Disease Control and Prevention guidelines. Journal of Clinical Anesthesia. 2007;19:360–364.

7. Yauger CY, Waite LK, Baker K, et al. Durability and disinfection of single-use endotracheal tubes following exposure to commonly available medical disinfecting compounds. Nursing Outlook. 2022;70–S135.