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15TH IFHE CONGRESS 1998

Perturbations
Affecting the
Performance of
Laminar Flow in
Operating
Theatres
by
C Hartung and J Kugler, Hannover, Germany

Introduction
Measures to reduce germs in operating areas and thus entailing risks
of infection had already been taken in the last century. Only by the
beginning of this century was the indispensable reduction of airborne
particles enabled by technical progress, eg particle counters to
quantify the actual hygienic situation; air-conditioning; protecting
overpressure; filtering; and humidification. The next important step of
progress was achieved in 1965, when Whitcomb et al.1 introduced the
technology of clean rooms to hospitals. The number of airborne
particles was reduced to such low levels that the wound infection rate
for treatments in bone surgery was acceptable. During the period after
1965 Charnley2, Lidewell3 and Whyte et al.4 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.
Considering that an average level of 2000 CFU/m3 is normally detected
in rooms for unspecified use, the effectiveness of laminar flow systems
is quite obvious.

Further improvement of laminar flow systems will be governed by

two divergent developments: economy reduction of operating
expenses will inevitably lead to less expensive air-conditioning with
lower performance; and hygienics the perceivable increase in resistance of germs against antibiotics will require more effective, and
hence more expensive, air-conditioning.
Thus the significance of managing the optimization and operation
of laminar flow facilities will increase; and the need for studying flow
under varying operating parameters is quite obvious in order to
provide the necessary knowledge.

Problem
Laminar flow systems operate on the basis of displacement flow5.
Germ-free air passes through a dense-meshed tissue to achieve low
turbulence. Normally the air inlet is positioned directly above the
operating area. Generally, the low inlet velocity does not suffice to
achieve a penetration of the inlet jet into the operating area. A
stabilization of the inlet jet by an extremely high inlet velocity, as
realized in industrial clean-room technology, would reduce the
comfort of the operating team in an intolerable way. Therefore the
temperature of the inlet jet is reduced below average room
temperature and thus sinks down into the operating area on account
of its higher density. As well as by temperature and velocity of the inlet
air, the resultant flow in the operating area is perturbed by thermal
buoyancy and obstacles such as operating physicians and medical
personnel, operating lamps, and medico-technical devices.
Hence, before surgical treatment the air-conditioning system undergoes standard testing in order to ensure a sufficient stable inlet jet.
Two standards have to be followed in Germany: DIN 1946, Part 4
Requirements of Hospital Air-Conditioning6 and DIN 4799 Test
Requirement of Air-Conditioning7. The latter forms the basis of
hygienic rating of air-conditioning quality. If one compares the
idealization and simplicity of required test conditions with the
complexity of performing flow, doubts simply must arise as to whether
test flow conditions occur in reality at all.
Thus, the targets of the present investigation are
to demonstrate the effect of thermal buoyancy and obstacles on
displacement flow by simulation; and particularly
to detect breakdowns of the inlet jet on account of varying
operating constellations.

Figure 1 Basic scenario dimensions and arrangement

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89

If so, perturbations, so far unknown, could be detected and be

eliminated, and time-consuming and costly investigations following
standard guidelines could be avoided or considerably reduced.

Figure 3 Asymmetric arrangement of obstacles generates a diversion

of inlet air jet to the left, thus bypassing operating area. Inlet air: Tinlet
= 20.5C, vinlet = 0.19 m/s.

Methods
Flow in operating rooms equipped with laminar flow systems develops
by forming two regions beneath the inlet: a core zone of low
turbulence from beneath the inlet to the operating area, and a
turbulent region in the rest of the room. The resulting flow process is
not at all simple, and requires turbulence modelling to simulate the
occurring constellations. Our present investigation is based on the socalled k model developed by Wilcox8. This model was especially
designed to simulate turbulent flow at low Reynolds numbers, as
occurring in operating theatres. The effect of heat sources is included
by Boussinesq-approximation. Mesh optimization proved that the
extension of the core zone of low turbulence strongly depends on
mesh resolution. If a coarse mesh has to be introduced, as in the case
of 3D simulations for restrictions in computer capacity, breakdowns of
the core zone are observed, which are obviously unrealistic. Hence, we
restrict our considerations to 2D simulations of the displacement flow,
meanwhile maintaining the necessary mesh density.
Figure 2 Scene 1 vector plot of flow velocity. The inlet air flushes the
operating area. Buoyancy-induced eddies only occur close by the
ventral side of both operators. Dark areas indicate areas of maximum
flow velocity, 0.3 m/s. Inlet air: Tinlet = 20.5C, vinlet = 0.19 m/s.

Results

The basic scene underlying this paper is depicted in Figure 1. The

actual scenario was generated by omitting and moving obstacles.
Computer simulations were carried out with the FEM based CFD-Code
FIDAP on an HP 9000.
The range of simulations covers:
surface temperatures of obstacles: lamp front 3050C, lamp
reverse 4575C, table 30C, operating personnel 30C;
inlet air: velocities 0.150.4 m/s, temperatures 1822C, laminar
inlet flow (turbulent kinetic energy k= 0 m2/s2);
walls, bottom, ceiling temperatures 1624C.
Though laminar flow systems function quite satisfactorily under
standard conditions, little is known about how they perform under
varying operating conditions as observed in reality and as a result of
perturbations such as obstacles and thermal loads. Perturbations are
generated by moving the lamp 0.3 m towards the operating centre
and by varying surface temperatures of lamp and walls. The inlet jet is
ranked stable if a moderate variation of influencing magnitudes does
not cause significant alterations of the displacement flow.

The efficiency of air-conditioning is proved by two ruling magnitudes:

turbulent energy k and vertical component vy of flow velocity.
The standard deviation of flow velocity is given by v = (2k/3)
enabling the calculation of the degree of turbulence Tu= v/v. The
degree of turbulence may serve as a guiding magnitude for engineers
and technicians who bear on-site responsibilities. The vertical velocity
component vy describes the effect of buoyancy and thus the risks of
germ induction into the inlet air.
The arrangement of flow obstacles in the operating area essentially
affects the performance of local flow. Position and size of inlet as well
as bifurcation of outlet flow do not affect the flow in the operating
area.
Symmetric positioning of lamps, table and of the operating persons
results in an almost symmetrical flow as depicted in Figure 2. Flow
velocities are significantly below 0.5 m/s in the working area of the
team, thus avoiding draught. The inlet air directly reaches the operating area. An upward flow is generated at the ventral side of the
operating individual.
If the flow obstacles are arranged asymmetrically, eg by removing
operator 1, the inlet jet tends to move upward flow and eddy, bringing
the risk of germ induction into the wound area (Figure 3).
Flow exhibits typical features despite the varying positions of
obstacles. The vertical component of flow vy at varying distances above
the table and on account of varying arrangements of flow obstacles is
depicted in Figure 4. The plots indicate an acceleration of the inlet jet
towards the table and a deceleration below a certain distance closely
above table level on account of its barrier function.
Plots of turbulent kinetic energy k reveal that severe eddies have to
be expected in the intimate vicinity of outlets only. Those occurring in
the remaining room areas are significantly weaker. Low turbulence, as
required, develops in the operating area (Figure 5). Focusing on the
operating area, an increase of turbulent kinetic energy can be detected
at the ventral side of the operators as well as on the upward side of
the lamps, indicating eddy release. Note that the release of eddies
induces higher turbulence than thermal buoyancy can.
Besides the arrangement of flow obstacles, operating parameters
such as inlet temperature and velocity essentially affect flow in the
operating area. The velocity plots of Figure 6 and Figure 7 serve as
examples. Differences of temperature between inlet air and averaged
room temperature and consequent buoyancy effects can be neglected
at inlet velocities vin= 0.4 m/s as applied in industrial clean-room
technology. If the inlet velocity is lowered to 0.21 m/s temperature
effects on flow velocity may be observed between 20C and 22C inlet
temperature. This temperature effect may be reduced by a dense
arrangement of flow obstacles around the operating area. Further

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15TH IFHE CONGRESS 1998

Figure 4 Response of relative vertical velocity vy/vinlet above table level on account of varying flow obstacles. Inlet air: Tinlet = 20.5C, vinlet =
0.19 m/s.

Figure 5 Spread of turbulent kinetic energy k in the operating area.

The core zone of low turbulence reaches down to table level. k
increases by increments k = 0.0025 m/s from core zone towards
adjacent turbulent regions. Inlet air: Tinlet = 20.5C, vinlet = 0.19 m/s.

Correlations exist between flow stability on account of local

variations in temperature and the above-mentioned effects of
temperature differences between inlet air and averaged room
temperature. Local heat sources do not perturb global flow in the
operating area as long as the inlet jet provides a sufficiently high inlet
velocity and temperature effects are omitted. If the effect of
temperature on flow is moderate, thermal buoyancy may occur in the
vicinity of lamps without affecting the core zone of low turbulence of
the operating area. At low inlet velocities temperature generally affects
flow. Local heat sources may result in buoyancy flow and consequent
global flow alterations. Note that small alterations in temperature may
thus lead to significant alteration in flow. Stable flow conditions can
then no longer be ensured.
Lowering the temperature of floor, ceiling or walls, or all jointly, may
cause destabilizing effects, if occurring in the temperature-sensitive
range of displacement flow. The same boundary conditions may cause
a stabilizing eddy between operating area and walls, if temperature
there is increased.
A move of a single lamp into the operating area results in a significant constriction of core flow, thus worsening hygienic circumstances
for as long as the operating surgeon is absent. If the lamp is directly
positioned above the surgeon and if vin <0.19 m/s, the existing eddy
on the ventral side of the surgeon is supported. Above vin = 0.19 m/s
a pressure gradient develops, resulting in a flow adjoined to the
surgeons body, thus leading to optimal hygienic circumstances. How
far this effect can be ranked as stable can only be evaluated experimentally.

lowering of inlet velocity from 0.21 m/s to 0.17 m/s at varying inlet
temperatures between 18C and 22C affects the flow considerably.
Flow still remains stable. Below inlet velocities of 0.17 m/s flow stability
ceases. The fact that turbulent kinetic energy hardly alters in the
operating area proves that flow instability is not caused by a transition
from laminar to turbulent mode but by alterations of flow profiles
resulting in generation of large eddies and flow deviations. In the
remaining areas of the operating theatre eddies increase with increasing inlet velocity and difference between inlet air temperature and
averaged room temperature.

Discussion and Perspectives

Three operating ranges have to be considered:
buoyancy is actually low at inlet velocities vin >0.21 m/s. Thus, socalled laminar flow systems must be operated at vin >0.21 m/s.;
the effect of buoyancy increases over a transition 0.21 m/s > vin >
0.19 m/s without significantly affecting flow in the operating area.
However, we do not recommend operating laminar flow
systems in this transition range, since the number of expected
irritations of displacement flow in reality may be higher than the
number of irritations which can be produced by simulations;

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Figure 6 Effect of inlet air temperature Tinlet on relative vertical velocity vy/vinlet at constant inlet air velocity vinlet = 0.19 m/s. Arrangement of
flow obstacles according to Figure 1.

Figure 7 Effect of inlet air velocity vinlet on relative vertical velocity vy/vinlet at constant inlet air temperature Tinlet = 20.5C. Arrangement of
flow obstacles according to Figure 1.
a stable displacement flow cannot perform at lower inlet
velocities. Supply to the operating area of germ-free air can then
no longer be guaranteed.
Obstacles (eg lamps, personnel and equipment) in the operating
area should be arranged symmetrically. Asymmetrical arrangement of
obstacles results in jet deflections and should be avoided. Heat sources

should be removed as far as possible from the operating area. If heat

sources are positioned close to walls they may stabilize the inlet jet by
inducing a wide eddy between wall and operating area. Thus, seasonal
effects must be considered in operating rooms with outer building
walls.
It should be emphasized that laminar flow systems can only be
operated appropriately if the inlet temperature is lower than the outlet

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References
1

5
6

7
8
Figure 8 Moving a lamp into the operating area causes constriction
and may lead to complete collapse of core flow on account of
inappropriate choice of operating parameters, such as inlet air: Tinlet
= 22C, vinlet = 0.15 m/s.
temperature. Thus, every operating room needs additional heating for
reasons of comfort. Laminar flow systems cannot be used stand-alone
to achieve both thermal comfort and hygienic safety.
Obstructing the operating area by lamps worsens flow conditions in
the operating area.
Hygienic quality increases with increasing dimensions of inlets.
Owing to operating restrictions in velocity as mentioned above,
however, larger inlets result in an increase of volume flow and
consequent energy expenditures. Thus an increased use of circulating
air is recommended. For reasons of personnel protection, however,
suction lines for anaesthetics and closed devices for anaesthesia must
still be provided.
Complementary investigations will elucidate the effects on flow in
the operating area by varying inlet dimensions and by an apron
surrounding the inlet. At present our findings are checked by experiments. Results of these will be presented at the conference.

CONTENTS

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