Building and Environment 44 (2009) 2284–2289

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Building and Environment

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Numerical simulation on a horizontal airflow for airborne particles control in

hospital operating room
Junjie Liu*, Haidong Wang, Wenyong Wen
School of Environmental Science and Technology, Tianjin University, 92 Weijing Road , Tianjin 300072, China

a r t i c l e i n f o a b s t r a c t

Article history: Provision of downward unidirectional clean air has been prevalent for decades in modern hospital
Received 21 November 2008 operating rooms (ORs) to protect patients and surgeons from infectious airborne particles and has been
Received in revised form found to be effective in reducing Surgical Site Infection (SSI), however, its shortcomings are inevitable. In
25 February 2009
this study we investigated an alternative of horizontal airflow pattern and the airflow performance in an
Accepted 14 March 2009
OR with a dimension of 300 cm long, 296 cm wide and 240 cm high. We also evaluated the effectiveness
of the horizontal unidirectional airflow to control infectious airborne particles through onsite test and
Keywords:
computational fluid dynamics (CFD) simulation method. The investigation was focused mainly on the
Horizontal airflow
Operating room influence of the medical lamps and the thermal plume with different airflow patterns around the critical
Infectious particle zone under the horizontal air supply system. Ultraclean air was supplied from a fan-filter unit. The
Numerical simulation patient and surgeon were assumed to be releasing 200 and 400 particles per minute, respectively. The
results show that when the air supply and return facilities are installed on the same lateral wall to keep
a state of horizontal flow ventilation in the OR, medical lamps and the thermal plume have no obvious
influence on the horizontal airflow patterns around the critical zone in the OR, and performance of the
air supply system is highly related to the relative position of the source to the wound.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction main factor influencing airflow patterns, thus counteracting the

Application of ventilating systems is well known to be the most
effective way to control Surgical Site Infection (SSI) caused by
airborne particles. Through the proper distribution of ultraclean air,
infectious particles can be effectively isolated and diluted in
hospital operating rooms (ORs) [1] and the SSI rate following
operations decreases greatly after cleanroom technology is applied
to OR [2,3]. At present, the widely adopted air distribution in the
critical area of OR as well as other unidirectional cleanrooms is
downward [4] unidirectional (laminar) flow, which is efficient in
creating an aseptic environment around patients [5–7].
Despite recommended as the regular design requirement [8,9], the
downward unidirectional airflow pattern has some disadvantages
according to current research [10]. The unidirectional airflow pattern
of downward airflow can be easily affected by medical lamps and
thermal plume around the wound [11,12]. Though some methods to
reduce these negative effects have been recommended sufficiently,
some disadvantages cannot be eliminated due to the vertical unidi-
rectional flow pattern [13]. Indoor obstacles are considered to be the
* Corresponding author. Tel.: þ86 22 27409500; fax: þ86 22 87401561.
E-mail address: jjliu@tju.edu.cn (J. Liu).
function of clean air in isolating infectious particles. Facilities placed
upstream of patients such as a medical lamp may cause serious
whirlpool and particulate accumulation [14]. In addition, since the
temperature of human surfaces is usually higher than the one of his
surrounding air, buoyancy-driven airflow plumes caused by the
temperature difference between the human surface and the envi-
ronment, with an upward airflow, can easily disturb the downward
airflow pattern formed by the ventilating system and carry infectious
particles to the wound, leading to serious surgical site infection in OR.
To avoid the disadvantages of the conventional airflow pattern
applied to operating room, an alternative of horizontal airflow
pattern should be studied to find out its feasibility, characteristics
and contamination control effect in OR. Since the main sources of
infectious particles and bacteria in an OR are the surgeons with
related to their activities, an airflow pattern formed to isolate
patient from surgeons will be effective in preventing SSI. A venti-
lation system with ultraclean air supplied from a lateral plane will
avoid the obstacles, such as medical lamps, from the upstream flow,
and the horizontal airflow with a direction perpendicular to the
airflow direction of thermal plume around surgeons and patient
can avoid counteractive effect between the two airflows in down-
ward airflow system. But, the application of horizontal formation of
airflow has not been adequately studied.

0360-1323/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.buildenv.2009.03.019
 J. Liu et al. / Building and Environment 44 (2009) 2284–2289 2285

The current prevalence of vertical airflow organization, in other

words the rare adoption of horizontal airflow organization reflects
its disadvantages. The existing design of horizontal airflow systems
in an OR usually causes a relative long distance between supply air
inlets and return air outlets, making it difficult to maintain
a washing effect around the patient with unidirectional flow. The
healthcare staffs and necessary furniture are serious obstacles to
damage the unidirectional airflow at most time. In order to produce
the horizontal airflow pattern, the clean air supply inlets and return
air outlets must also be installed on two opposite vertical walls [15],
making necessary a sizable space within walls (interlayer) to allow
air transportation, thus decreasing the effective occupational area
ratio of a building. To avoid such disadvantages, an OR with a new
style of horizontal airflow pattern was specially studied for this
investigation.

2. Methodology

2.1. Onsite investigation

An actual hospital OR was designed and built either as a ward of

patients at high risk of infection or for simple operation. To avoid
disadvantages of the horizontal unidirectional airflow in an OR, the
dimension of the OR was properly designed to make the fan-filter
Fig. 2. Ground position of vertical poles for air velocity comparison.
unit (FFU) close to the prospective patient. The air supply and
return facilities were installed on the same lateral wall of the OR,
only one interlayer was needed for air handle equipment and
a partition was set between FFU and return grille to prevent short anemometers to validate the numerical model employed in the
circuit of the airflow. The independent ventilating system forced an study. The hot-sphere anemometers employed in the measurement
air circulation between FFU and return grille in the room with have the resolution of 0.01 m/s and accuracy of 3% of reading.
necessary outdoor fresh air and maintained positive pressure.
The counting efficiencies of terminal high efficiency particle air 2.2. Numerical simulation
(HEPA) filters in FFUs were 99.99%, based on dioctyl phthalate
(DOP) test of particles at 0.3 mm. Dimensional size of the OR was Reynolds Averaged Navier–Stokes equations were employed to
300 cm long, 296 cm wide and 240 cm high as shown in Fig. 1. A bed solve the airflow field. They can be expressed as:
was located in the center of the occupational area. One or two
vr vrui
surgeons would be at both sides of operating desk. Two medical þ ¼ 0
lamps were installed on ceiling for the operation.
vt vxi
Face air velocity of FFU and airflow rate of return air grille were ! !
tested to set necessary boundary condition in numerical simula- v v  vP v vui vuj
ðrui Þ þ rui uj ¼  þ m þ  ru0i $u0j þ Si
tion. The locations of vertical poles to test air velocities are shown vt vxj vxi vxj vxj vxi
in Fig. 2. The air velocity data was measured by hot wire

Fig. 1. Sketch of the OR (mm).

2286 J. Liu et al. / Building and Environment 44 (2009) 2284–2289

where r is the fluid density, t is the time, xi is the coordinate, ui is

the velocity components, m is the fluid viscosity and Si is the source
term.
Reynolds stress:
!  
vui vuj 2 vu
ru0i $u0j ¼ mt þ  rk þ i dij
vxj vxi 3 vxi

dij is Kronecker factor, mt is the turbulence viscosity and k is the

turbulence kinetic energy.
As for indoor turbulence modeling, two-equation k–3 model
proves to be practical to predict turbulent flow field [16,17]. Related
to different k–3 models, RNG k–3 model is applicable for displace-
ment airflow and recommended to have better performance than
standard k–3 model for prediction of air velocity in indoor envi-
ronment [18]. But for an OR, due to the relative low level turbu-
lence, standard k–3 model is more applicable for airflow prediction
[18]. The well-established RANS equations and standard k–3 model
will be employed to calculate the airflow field in the OR, and the
result is used for both evaluating airflow pattern and calculating
particulate transportation.
The first step of numerical simulation is validation of the
Fig. 3. Layout of the OR under simulation.
turbulence model adopted for airflow simulation. A full size model

Fig. 4. A comparison of velocity profile (symbol: measurement; line: simulation).

 J. Liu et al. / Building and Environment 44 (2009) 2284–2289 2287

Fig. 5. Airflow pattern in vertical intersection.

was built as the OR without facility and occupant in, and air velocity
profiles along the 6 vertical poles as shown in Fig. 2 were obtained
from numerical results to compare with the test results. The vali-
dated turbulence model was then used to evaluate airflow pattern
under a hypothetic simple operation in the OR. The layout of the OR
under such operation is shown as Fig. 3. A patient was laid on a bed
in occupational area with two surgeons beside him. Two medical
lamps were fixed beneath the ceiling. Particle concentration field
was also analyzed and simulated for optimization of the OR.
Airborne particles are the main carriers of bacteria that cause
post-operative infection and there is a close relationship between
the colony-forming unit (CFU) and the counts of particles with
diameter 5 mm [2], and the main source of bacteria in OR is
skin scales or particles ranged from 5 to 10 mm in diameter.
Since bacterial counts are determined as CFU, particles with
diameter 5–10 mm can be considered as infectious particles [19].
Control of airborne particles with this diametric range is crucial to
hospital OR.
Different diameters including 5 mm, 7 mm and 10 mm were
calculated and tiny difference was found among the results, thus
a uniform distribution of diameter of 5 mm was assumed as the
infectious particle diameter, harmful particles released by surgeons
in OR were also supposed to be monodisperse with a diameter
of 5 mm.
Density of single particle in the OR also has great influence on
the transportation of particle once gravity is taken into consider-
ation. Particles in OR are the main source from surgeons and
facilities, hence density of single particle is different and is difficult
to determine. The diversity of particulate density was supposed
to be 2 g/cm3 in this study [11], which can be representative.
Particle releasing rate from sources in OR is another important
element that affects the result of simulation. As infectious particles
are concerned, number of bacteria colonies released by surgeons
can reflect the number of particles. Zhang et al. [20] set this value
to be 400 particles/min person for lower part of the body and
200 particles/min person for upper part of the body after a series of
investigations. As surgeons wear clean clothes preventing partic-
ulate release, particles are mainly released from upper body such as
collar and face and front side of the surgeon. The total particulate
release rate was set to be 600 particles/min person (equal to
1.31 1012 kg/s) for a surgeon and 400 particles/min person
(equal to 8.72  1013 kg/s) for a patient.

Fig. 6. Particle concentration field under an operation (g/m3).

2288 J. Liu et al. / Building and Environment 44 (2009) 2284–2289
Fig. 7. Particle concentration field under different layouts (g/m3).
A sophisticated Lagrangian model proven to be reliable [21] was
employed for particle concentration field simulation. One-way
coupling of interaction between particle and air was assumed.
Trajectory information calculated through such model can be
expressed in the form of concentration field by particle source in
cell (PSI-C) method [22].
3. Validation of turbulence model
Air velocity near the FFU was tested in 64 sampling points to get
the necessary boundary condition for CFD simulation. The probes
should be positioned at a distance of 15 cm from the perforated
panel of HEPA filter face. Through measurement, the mean air
velocity is 0.32 m/s with a standard deviation of 0.05. A uniform
velocity of 0.32 m/s was thus set to be the boundary condition of
the FFU. In validation stage, no internal load was in the OR and an
isothermal condition was assumed.
The whole OR with objectives excluded from the inside space
was discretized. Unstructured grid and hybrid discrete scheme was
adopted. The mesh size was locally refined near the FFU because of
the larger velocity gradient in this region. Grid-independency was
achieved by refining the mesh size when the total number of the
meshes reached 1.7  107. SIMPLE algorithm was employed in the
pressure–velocity coupling calculation [23]. Fluent was used as
the computation software in the numerical simulation. Fig. 4 shows
a comparison of air velocity profiles in the 6 vertical poles. The
results were acquired under condition without bed, patient or
surgeon in the OR.
The result of simulation is in good agreement with measured
data, and the difference between the two is negligible, revealing
that standard k–3 model performs well for air velocity prediction in
such OR, simulating result can provide a reliable reference in
evaluating ventilation system of the OR. All conclusions hereby
obtained through numerical simulation are based on this point.
4. Investigation of the airflow pattern
In the airflow simulation, a non-isothermal condition was
assumed, the power of each lamp was set to be 100 W, and power of
each person was set to be 130 W. Thermal plume with an upward
direction is perpendicular to the main stream under horizontal
airflow organization, thus has less effect on unidirectional airflow
than under vertical airflow organization.
For traditional vertical airflow organization in OR, airflow
pattern around a patient can be seriously affected by upstream
obstacles such as medical lamps, which can weaken the washing
effect of the supplied ultraclean air. Under horizontal airflow
organization, the airflow pattern can be seen in Fig. 5.
The simulated airflow pattern on vertical sections across
a medical lamp and across the patient indicates that medical lamp
has no harmful effect on unidirectional flow around the patient.
Horizontal airflow exhibits a good washing effect beside the
patient, effectively avoiding harmful influence of medical lamp and
thermal plume on airflow pattern under vertical airflow organiza-
tion as indicated in a literature [11].
5. Concentration field simulation
Under horizontal airflow ventilation system, particle concen-
tration of critical zone can be highly related to position of source
and position of occupants. During some surgeries, patient can be
well protected and motionless without releasing any particle, but in
other surgeries, particles are released from the lying patient. Fig. 6
shows the different particle concentration (g/m3) fields of a hori-
zontal surface right above the patient under these two conditions.
When there were particles released from the patient, particle
concentration around the patient increased evidently, promising an
increasing chance of post-operative infection. We can conclude that
it is important to control the particles released from the patient.
Reverse the direction of the patient to acquire the particle
concentration distribution. To maintain a low concentration in
critical area, the critical area should be set in the upstream of the
source position. Fig. 7 shows the particle concentration distribution
with the patient releasing the same amount of particles under
different layouts of the OR.
Particle concentration of the critical zone surrounding the
patient decreased obviously when the patient was reversed from
the original condition. Suppose a caecectomy was operated, post-
operative infection was more likely to occur due to the higher
concentration of the surgical area under the layout when the upper
body of the patient faced the FFU. In OR with horizontal ventilation
system, the particle concentration distribution is highly related to
the particle source position.
 J. Liu et al. / Building and Environment 44 (2009) 2284–2289
6. Conclusions
Horizontal airflow pattern can provide an important alternative
to operating room ventilation airflow design. When the air supply
and return facilities are installed on the same lateral wall to generate
a horizontal unidirectional flow ventilation in the OR, the medical
lamps and thermal plume induced by temperature difference
between people and environment have no obvious influence on the
airflow pattern of the occupant area, and the airflow pattern is easy
to keep unidirectional. Horizontal ventilation system performs well
in avoiding the influence of the surgeons to the patient. Particles
released by surgeons can be wiped off effectively, without leading to
the increase of the particle concentration surrounding the patient.
The risk of post-operative infection can thus be decreased signifi-
cantly. Particle concentration surrounding the patient is highly
related to the relative position of the source and layout of the OR. To
maintain a low particle concentration surrounding the patient,
especially around the wound area, the direction of the patient should
be prescribed correctly, according to the character of the surgical.
The main principle to set the layout is to make sure that the main
source of particle is in a downstream location of the wound area.
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