CFD ASSESSMENT OF OPERATING ROOM

HVAC SYSTEMS DESIGN

Mahmoud Fouad* and M. Osama El samadony**

* Professor ** Graduate research student

Mechanical Power Engineering Department, Cairo University, Egypt
Faculty of Engineering, Cairo University, El-Gamma Avenue, Giza, Egypt

ABSTRACT
In this paper computational fluid dynamics (CFD) techniques are used to evaluate the
efficiency of operating room HVAC systems in minimizing the risk of postoperative infection.
Seven different design configurations of operating room HVAC systems have been compared
numerically to assess their agreement with international standards of operating room
ventilation and airflow pattern requirements. The ventilation systems designs considered are
built-in using different air outlet devices, usual, laminar, non-aspirating, and slot diffuser
types. The airflow pattern of each configuration has been analyzed in terms of airflow
vectors, velocities, and turbulent intensity, and pollutant concentration distribution. It was
concluded that all the systems except for the non laminar flow one fulfilled well the
requirements of operating room ventilation, but, that unidirectional airflow with curtain and
zoned exponential unidirectional airflow configurations are the most versatile and energy
efficient.

Keywords: CFD, HVAC, operating room, anesthetic gases, Nitrous Oxide.

INTRODUCTION
Operating room is a complex environment that
requires ventilation for comfort and to control
hazardous emissions for patients, and surgical
staff. Indoor air quality is more critical in health
care facilities than in most other indoor
environments due to many dangerous microbial
and chemical agents present and due to the
increased susceptibility of the patients,
especially immunosuppressed persons.
The contamination of operating room air with
microbes and viruses is considered as a major
risk factor for surgical site infection (SSI). It
was been reported that 80-90% of bacterial
contamination found in an open wound comes
from ambient air1. Operating room air may
contain microbial-laden dust, lint, skin squames,
or respiratory droplets.
Lidewell2 and Whyte et al. intensively studied
the transmission of airborne germs in operating
rooms. These investigations resulted in the
finding that hygienic safety was definitely
achieved if less than 10 CFU*/m3 air was
detected in the operating area.
Several factors can affect postoperative
infection, including patient factors (e.g.,
susceptibility to infection), surgical field factors
(e.g., the thermal plume from the site), room
factors (e.g., cleanliness of the operating room),
and HVAC factors (e.g., air change rate [ACH]
and direction of airflow).
Healthcare personnel can also react negatively
to cleaning materials, sterilants, disinfectants,
and anesthetic gases.
The anesthetic gas and vapors that leak out and
into the surrounding room during medical

* CFU - Colony Forming Unit

1 1st. National conference on “Human performance in health and disability”, Egyptian Society of Fitness, Disability & Environmental Health
(ESFDEH), March 10-11, 2004, Cairo.
procedures are considered waste anesthetic
gases, including nitrous oxide and halogenated
agents (vapors). Exposure to these waste gases
usually results from poor work practices during
the anesthetization of patients, leaking or poor
gas-line connections, improper or inadequate
maintenance of the machine, and/or patient
exhalation after the surgical procedure, while in
recovery.
Exposure to these gases with concentration
beyond the hygienic threshold limits and for a
considerable time adversely affects health.
Some potential health effects include nausea,
dizziness, headaches, fatigue, irritability, and
drowsiness, problems with coordination and
judgment, as well as sterility, miscarriages, birth
defects, cancer, and liver and kidney disease.
The purpose of this study is to numerically
analyze and evaluate the performance of seven
different HVAC systems configurations in order
to assess their agreement with international
standards of operating room ventilation and
airflow pattern requirements.
INTERNATIONAL DESIGN STANDARDS
Due to the obvious importance of operating
room air quality, Standards were suggested by
different countries and organizations specifying
the operating room parameters and
requirements. The 1999 ASHRAE Handbook—
Applications3 suggests “the delivery of air from
the ceiling, with a downward movement to
several exhaust inlets located on opposite walls,
is probably the most effective air movement
pattern for maintaining the concentration at an
acceptable level.” Besides, it suggests that the
temperature range should be between 62°F
(16.67°C) and 80°F (26.67°C), and that positive
pressurization should be maintained. Further, It
suggests that the air should be supplied at the
ceiling and exhausted or returned from at least
two locations near the floor. It suggests that
supply diffusers should be of the unidirectional
type, and that high-induction ceiling or sidewall
diffusers should be avoided. The suggested
ACH is 15 for systems that use all outdoor air,
and 25 ACH for recalculating air systems.
2
OPERATING ROOM - DESIGN
APPROACH
Proper design and ventilation of operation
theatres is the most important means of
controlling air borne contamination and thus
preventing air borne infection in operation
theatre. There is no unique design for operating
theatre air-conditioning, as there are many
possible approaches.
Operating Room Model:
The operating theatre under investigation is
6.9m in length, 6.1 m in width, and 3.25 m in
height having an operating table located in the
center of the room with 2.0 m length and 0.5 m
width and 1.0 m height. A point source
representing the anesthetic gas (Nitrous Oxide,
N2O) leaking from the anesthesia machine was
located at (4.8, 1.05, 2.05) with an emission rate
of 8.08 mg/s. The mass diffusivity of Nitrous
Oxide in air was estimated using Fuller,
Schettler, and Giddings (FSG) as 1.78 *10-5
m2/s.
HVAC Systems Design Configurations:
Seven different design configurations of the
operating room ventilation system were
investigated with details illustrated in table - 1.
These seven layouts (figure 1) can be generally
classified according to their flow pattern as
follows:
1. Non-laminar (turbulent) airflow: In the
early days of conditioning surgical spaces
and before the evolution of “laminar air flow
(LAF)” pattern, directional airflow was not a
major consideration, The conventional
design was sidewall supply diffusers throw
air under pressure to mix with the occupied
zone air diluting contaminants. Such
configuration is considered in this work for
just comparison as an extreme case for
operating rooms HVAC design.
2. Vertical unidirectional airflow: where the
air is supplied from a ceiling mounted
perforated non-aspirating (no mixing of
room air with supply air) grilles at low
velocity (quasi-laminar) and directed toward
the operating table scavenging contaminants
 Table 1: Details of cases considered in study.

Volume Supply
Case

HVAC Supply Diffuser Exhaust Diffuser

ACH flow rate velocity
system Details Details
m3/s m/s

1 Type: Type: 18.00 0.684 1.56

Non-Laminar
Conventional

Two conventional supply grille of Four conventional exhaust grilles of

System

0.61 m * 0.36 m. 0.36 m * 0.36 m.

Position: Position:
Both located at high-level (one side), Located at low-level, 0.25 m from the
0.25 m from the ceiling. floor. Two on the supply ATDs wall,
and the others on the facing.

2 Type: Type: 166.15 7.734 0.15

Vertical LAF

Large array of laminar perforated panels. Two conventional exhaust slot shaped
Complete

System
Ceiling

Position: grilles of 6.1 m * 0.36 m.

Covering the entire ceiling with a supply Position:
area of 6.9 m * 6.1 m. Located on the end walls at low-level,
0.25 m from the floor.

3 Type: Type: 20.00 0.760 0.20

Array of laminar perforated supply Eight conventional exhaust grilles of
Vertical LAF
Small-Area

panels with 2.4 m * 1.6 m supply area 0.36 m * 0.36 m.

System

Position: Position:
Mounted at ceiling immediately above Two 4-grilles groups are mounted on
the operating site. each sidewall (symmetrically distributed
over the wall with 0.25 m from floor,
ceiling, and end walls).

4 Type: Type: 23.12 Central 0.40

■ Central/Ultra-clean zone: An arrays Four conventional exhaust grilles of zone 0.691 at C-zone
Unidirectional Airflow System

of laminar supply panels having 30% 0.61 m * 0.36 m.

With Deflecting Walls

perforations, with 2.4 m * 2.4 m central Position: & &

Zoned Vertical

supply area. Located at low-level, 0.25 m from the

■ Peripheral/Clean zone: An arrays of floor. Two on one sidewall, and the Peripheral 0.20
laminar supply panels having 13% others on the facing one. zone at P-zone
perforations, with a width of 0.6 m 0.187
around the core zone. And is enclosed
by hung deflection walls of 1.0 m With a
length. total of
Position: 0.878
Mounted at ceiling immediately above
the operating site.

5 Type: Type: 25.00 0.950 0.18

■ Center laminar flow diffusers array Four conventional exhaust grilles of at LAF
with 1.8 m * 1.2 m supply area 0.32 m * 0.32 m. Panel
Vertical LAF

Air-Curtain

supplying one-third of the room ACH. Position: &

■ Perimeter slot diffusers of 12.48 m
With

The four exhaust grilles are 1.27

perimeter-length, enclose the operating symmetrically distributed over all walls at curtain
area in a linear air curtain. at low-level, 0.25 m from the floor (one projected 5o
Position: for each). Outward
Mounted at ceiling immediately above op. area
the operating area.

6 Type: Type: 20.85 0.792 0.25

Arrays of laminar supply panels having One slot shaped exhaust grilles.
30% perforations, with 3.25 m*3.25 m Position:
Deflecting Walls
Horizontal LAF

supply area, and equipped with two 1 m Located on the facing end-wall at low-
length deflection walls. level, 0.25 m from the floor.
With

Position:
Located at end wall in front of the
operating site, and with 1.3 m from the
foot-end of the operating table

7 Type: Type: 33.00 1.254 0.15

Piston ventilation arrangement
for ultra-clean operating room

■ Main supply: Arrays of laminar A large floor mounted exhaust was at LAF
supply panels having with 2.96 m*2.36 used having an area of 3m*2.4m. main Panel
m supply area to ventilate the surgery Position:
zone. Located at floor in the center of the
■ side supply: Low induction arrays of room &
supply air terminal device (ATDs)
having a width of 0.12.m for the 0.16 at the
ventilation of the room remainder. side supply
Position:
Mounted at ceiling immediately above
the operating area.

3

from it. Return or exhaust air is taken in
multiple locations at the floor level to create
a “once-through” pattern. This design is
widely used with different arrangements;
entire LAF ceiling, array of LAF diffusers
concentrated above surgical zone, and array
of LAF diffusers concentrated above
surgical zone with extending walls or air-
curtain Peripherally surrounding the LAF.
3. Horizontal laminar airflow: where the air is
supplied from perforated low induction air
diffusers mounted at one wall directed
toward the operating table.
4. Piston ventilation airflow:
a unidirectional flow of air in which outdoor
air propels the contaminated room air ahead
of it like a front. The room air is
continuously ’swept’ by outdoor air and
little spread of contamination generated
4
Figure 1: Seven cases with different HVAC systems design
configurations.
within the room takes place before this is
carried by the outdoor air to the extract duct.
This method of ventilation is employed in
’clean rooms’, but to be effective the air
turbulence must be reduced to a minimum
so that contaminant dispersion is minimized.
NUMERICAL METHOD AND
BOUNDARY CONDITIONS
Computational Fluid Dynamics (CFD) was used
to model the air movement in a typical operating
room under different HVAC systems
configurations.
CFD modeling was conducted to study airflow
patterns, in order to evaluate the effectiveness of
the proposed ventilation systems designs.
A commercial CFD program was used in this
isothermal numerical analysis.
By discretizing the room volume into an
unstructured grid of finite volumes or cells
(Table-3), where a set of partial differential
governing equations for mass and momentum equations. Typically, it is assumed that all mass
can be numerically solved. Mesh refinement and flux across any solid wall is zero and the no-slip
adaptation were used in order to reach a grid condition is applied on the solid walls. The wall
independent solution. function is implemented near the walls in order
to avoid using too many grid points in the
Governing equations It is assumed that the air viscous sub-layer. The mass flow rate of air
is incompressible, homogeneous, and isotropic. supply is adjustable. Before entering the
Furthermore, the three- dimensional airflow in domain, the air flows through a pre-filter to
the working area is steady and maintained at leach larger particles and then flows through a
room temperature. As a result, the physical HEPA filter. Therefore, the inlet air is regarded
problem can be represented by the laws of as a unidirectional uniform flow in the analysis.
conservation of mass, momentum (u, v, w), as The implemented boundary conditions are listed
well as the transport laws of mass diffusion to in the proceeding table (Table-3).
compute for contaminant distribution. Besides,
the k-ε model is also used to describe the flow Table 3: Numerical Conditions
turbulence with the transport equations of
Mesh CASE 1 53536
turbulence kinetic energy (k) and its dissipation
CASE 2 48484
rate (e) involved in the computations. All these CASE 3 56577 Unstructured
equations can be expressed in a general form: CASE 4 53636 tetrahedral
CASE 5 59373 cells

∂( ρφ ) ∂  
(ρφ ui ) = ∂  Γφ ∂φ  + Sφ
CASE 6 53244
+ (1) CASE 7 54764
∂t ∂xi ∂xi  ∂xi  Turbulence Standard k- ε model.
Model
Inflow Boundary Uin; shown in table 1,
Where φ is the dependent variable, Table-2 Condition k= 3/2(Uin*Ti)2,
gives the expressions for the source terms Sφ for ε = Cμ 3/4 kin3/2 / l0 ,
each variable that is likely to be needed in l0 =Length scale of supply opening
=0.1 Lin ,
solving ventilation problems. Lin = The characteristic length of
the diffuser.
The numerical algorithm made use of the Ti = Turbulence intensity.
= 0% for perforated LAF ATDs
"SIMPLE Solving Algorithm" [Semi Implicit = 4-10% for other non-laminar
Method for Pressure Linked Equation], for airflow diffuser.
pressure - velocity coupling. Outflow Uout, kout, ε out free slip wall.
boundary
Condition
Table 2: Source Terms in the Transport Equations for Wall Treatment Generalized log law.
Turbulent Flow Uniformly and continuously generated
Contaminant
Equation φ Γφ Sφ throughout the space, simulated with
Continuity 1 0 0 species full transport equation.
Momentum ui μe - ∇P+∇· (μe ∇· U) + ρg
Kinetic Energy k Γk Pk - ρε
Dissipation rate ε Γε C1ε ε Pk / k - C2ε ρε2/k
Concentration C Γc ρCs
RESULTS AND DISCUSSION
The efficiency of air conditioning in the
Where σk =1.0 , σε =1.3, σC =1.0, Cμ =0.09, C1ε =1.44, C2ε=1.92
Cµ ρ k 2
operating room is proved by three ruling
µt = , magnitudes: turbulent energy k, velocity pattern
ε
 ∂u ∂u  ∂u
V of the flow, and the concentration of
Pk = µt  i + j  i anesthetic gas (N2O) at breathing height which
 ∂x j ∂xi  ∂x j
 
is 1.5 m above the floor level.
The standard deviation of flow velocity is given
Boundary conditions: The conditions on the ½
surfaces bounding the domain must be clearly by v’ = (2k/3) enabling the calculation of the
defined in order to solve the system of transport degree of turbulence Tu= v’/v. The degree of

5
turbulence may serve as a guiding magnitude
for engineers and technicians who bear on-site
responsibilities. The velocity of air describes the
effect of particles re-suspension and thus the
risks of germ induction into the inlet air.
Position and size of inlet affect the flow in the
operating area as in all the cases of study the
inlet air is directed to the operating suite,
conversely the exhaust grilles position affects
only the out less clean zone of the room and the
contaminant distribution. Flow velocities are
significantly below 0.5 m/s in the working area
in all cases, thus avoiding draught.
The inlet jet is ranked stable if a moderate
variation of influencing magnitudes does not
cause significant alterations of the laminar flow.
Flow exhibits typical features despite the
varying positions of obstacles. The vertical
component of flow Vy at varying distances
above the table where turbulent flow occurs,
however for laminar flow cases these
turbulences has too low kinetic energy
(k<<0.002 m2/s2).
In order to make the results from contaminant
concentration distribution more representative
for zones of anesthetic gases exposure risk, the
N2O concentration was normalized by the
standard threshold limit value (TLV) of the
contaminant.
Case 1:
The first design configuration evaluates the
performance of ventilation system using mixing
flow. Figure 2 shows the CFD results with the
species transport and airflow pattern. The results
are available for all three dimensions, but the
figures illustrate the results only in two sections,
a vertical section at the center plane of the
operating room and a horizontal section at the
breathing level to assess the exposure risk of
surgical staff to the anesthetic gas (N2O).
The contaminant is hasted with the jet from the
inlet diffuser causing it to spread in front of it,
reaching a maximum value of 282.5 ppm at the
breathing level. Besides, the velocity flow
pattern (figure 2) and profile of kinetic energy
shows high turbulence intensity at the operating
table and the working space.
6
That makes it more risky for infection, and thus
omitted from use in operating rooms.
Case 2:
A smoothly laminated air was depicted by the
velocity profile (figure 3). The eddies occurred
at edges of the table where air is sticking has
low intensity compared with case one. The one
deficiency of this configuration is the air
change, which amounts 166 ACH with running
and installing costs.
Case 3:
In the profile of velocity contour (figure 4), the
laminar jet coalesces a bit as it goes away from
the diffuser resulting in a smaller area covered
with laminar flow at the operating table. This
may result in shortage in safety from infection.
This can be solved by adding either deflecting
walls or by increasing the area of LAF diffusers
as occurred in case 4.
Case 4:
4
The zoned LAF system (figure 5) showed
within-standards velocity besides a low
turbulence kinetic energy with only 23.12 ACH,
that make it also an energy efficient solution for
operating room ventilation.
Case 5:
The flow seems low a bit at operating table and
the whole curtained zone (figure 6). It may be
for deficient simulation of LAF diffuser. The
curtain acts as a barrier preventing contaminants
from the outer zone to come through.
The demerit that was in this configuration is
dead zones outside the curtain; this has been
overcome by adjusting two arrays of four
conventional grilles well distributed at each
sidewall. It is thought to be a great innovation in
operating room ventilation.
Case 6:
The horizontal LAF showed somewhat high
velocities (figure 7) at the surgical zone. The
use of deflecting walls takes a room of the
operating theatre making it more confined. And,
it is thought that it will deflect greatly from that
showed pattern in non-isothermal studies.
Besides if the surgical staff and medical devices
are taken in consideration, they will act as
blocking barriers in its way, therefore it is not
recommended to be used.
Case 7:
The piston ventilation HVAC system
configuration that is real laminar airflow
showed excellent agreement with standards at
the surgical zone. The velocities above the
operating ranges from 0.11 to 0.17 as stated in
recommendations. The turbulence kinetic
energy is of 10-4 order of magnitude (<< 0.002),
that shows a real laminar flow.
Besides, at the breathing level (1.5 m above
floor) the concentration of the anesthetic gas is
maximum 8 ppm that is so far safe from the
hygienic limit (50 ppm).
The only defect in this configuration is the
highly expensive initial and running costs.
CONCLUSION AND MAJOR FINDINGS
The CFD modeling provided a great deal of
information the designers would not otherwise
have had. It was instrumental in comparing
between various operating room configurations
in a cheap easy manner.
From the seven configurations, the forth and
fifth cases are recommended, namely the zoned
LAF system and the vertical LAF with curtain
as they divided the room into zone ultra-clean,
clean, and less clean zones, fulfilling the
recommended direction of airflow which is
almost important and should be from clean to
less clean area preventing back flow into cleaner
one.
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airborn particle concentration and draught
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Blowers, R, Stanley, SJ and Lowe, D,
“Effects of ultra-clean air in operating room
on deep sepsis after total hip or knee
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285, pp 10-14, 1982.
7
3- Friberg B, Friberg S, Burman LG.
“Inconsistent correlation between aerobic
bacterial surface and air counts in operating
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for surface contamination.” J Hosp Infect
1999; 42: 287-293
4- ASHRAE2003-application Handbook.
5- Friberg B. “Ultraclean laminar airflow Ors”.
AORN J 1998; 67:841-51.
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risks of surgery”, ASHRAE Journal, Feb.
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of operating room ventilation systems in
protection of the surgical site”, ASHRAE
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P.G. 1995. Evaluation of computer flow
modelling in operating theatres, Proc.13th
Int. Symp. on Contaminant Control, The
Hague, The Netherlands.
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Affecting the Performance of Laminar Flow
in Operating Theatres”, 1998.
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Theatres: New Prospects in HVAC System
Design - Mazzacane S, Italy (UoF) 11-
11- Y. Liu, A. Moser, “Airborne particle
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Infection Control in Health-Care Facilities,
Centers for Disease Control and Prevention
(CDC), U.S. Department of Health and
Human Services, 2003.
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8
/exponential LAF-screen. A promising new
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 Figure 2: Computed air and contaminant distribution for case 1:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) Contaminant distribution at breathing level, 1.5m from the floor
9
 Figure 3: Computed air and contaminant distribution for case 2:
(a) Air velocity in middle section (z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) contaminant distribution at breathing level , 1.5m from the floor

10
 Figure 4: Computed air and contaminant distribution for case 3:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) contaminant distribution at breathing level , 1.5m from the floor
.

11
 Figure 5: Computed air and contaminant distribution for case 4:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) Contaminant distribution at breathing level, 1.5m from the floor
.

12
 Figure 6: Computed air and contaminant distribution for case 5:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) Contaminant distribution at breathing level, 1.5m from the floor
.

13
 Figure 7: Computed air and contaminant distribution for case 6:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section, (z=3.05)
(c) contaminant distribution at breathing level , 1.5m from the floor

14
 Figure 8: Computed air and contaminant distribution for case 7:
(a) Air velocity in middle section(z=3.05), (b) Turbulence kinetic energy in middle section(z=3.05),
(c) Contaminant distribution at breathing level, 1.5m from the floor
.

15
16