ANMF EVIDENCE BRIEF

COVID-19: NEGATIVE
PRESSURE ROOMS
Author: Dr Micah DJ Peters Date: August 14 2020
Question: What is the best available evidence regarding the use of negative pressure rooms for care of
COVID-19 patients?

*ALERT* Evidence regarding COVID-19 is continually evolving. This Evidence Brief

will be updated regularly to reflect new emerging evidence but may not always
include the very latest evidence in real-time.

Key messages:
• Isolation rooms, including negative pressure rooms, are designed to control the airflow in the room so
that the number of airborne infectious particles is reduced to a level that diminishes the risk of cross-
infection of others.
• Negative room air pressure is designed to protect others outside the room from any airborne
transmission from a patient who may be an infection risk inside the room.
• Health and aged care workers should be aware that, uncovered, coughing and sneezing, and in some
instances, speaking can generate small droplets and aerosols that may travel several metres, remain
airborne, and collect on surfaces. While the infection risk, particularly of smaller aerosolised particles, is
as yet not well understood, this highlights the importance of careful risk assessment and infection control
measures for airborne transmission risk particularly in crowded, poorly ventilated, indoor environments.
• Personal protective equipment precautions for airborne transmission should be observed in high-risk
areas e.g. (ICU, COVID-19 wards, negative pressure rooms) where aerosol generating procedures take
place including collection of respiratory samples including for asymptomatic patients (bronchoalveolar
lavage and induced sputum), and when providing frequent and/or close-contact care for people with
suspected or confirmed COVID-19.
• Patients should be placed in a negative pressure room if an aerosol generating procedure is to be
performed.
• If available, negative pressure rooms should be used for the collection of respiratory samples from
patients with suspected COVID-19.
• In Australia, negative pressure rooms should comply with the guidelines outlined by the Australasian
Health Infrastructure Alliance.

• In the absence of negative pressure rooms, newly developed intensive care ventilation hoods, some
of which are able to maintain small negative pressure environments around a patient’s head and upper
body, may reduce the potential for the spread of aerosolised droplets. As with all new technologies,
there must be careful consideration of safe and effective use.

ANMF EVIDENCE BRIEF: COVID-19: Negative pressure rooms | August 14 2020 1

 Summary
Background: COVID-19 (from ‘severe acute respiratory syndrome coronavirus 2’ (or ‘SARS-CoV-2’) is a
newly discovered (novel) coronavirus first identified in Wuhan, Hubei province, China in 2019 as the cause
of a cluster of pneumonia cases.1 Coronaviruses are similar to a number of human and animal pathogens
including some of those which cause the common cold as well as more serious illnesses including severe
acute respiratory syndrome (SARS/ SARS-CoV-1) and Middle East respiratory syndrome (MERS). Since
discovery, COVID-19 has spread to many countries and was declared a global emergency by the World
Health Organization (WHO) on 30 January 2020,2 and a pandemic on March 11.3

There is ongoing research and debate regarding the degree to which smaller respiratory droplets contribute
to the spread of COVID-19.4 Many jurisdictions nationally and globally have now adopted infection control
measures for the management of airborne transmission based on emerging evidence and pressure to
strengthen infection control and protection policies.5,6

The individuals most at-risk of infection are those in close contact with patients with COVID-19 which
includes health and aged care workers. Use of negative pressure rooms, which prevent air from
circulating to other areas in the building, are recommended where available, to minimise the potential
risk of transmission via smaller respiratory droplets.6 Negative pressure rooms have been recommended
since early on during the pandemic in the context of aerosol generating procedures and the collection of
respiratory samples where possible.

COVID-19 transmission: droplets, surfaces, and aerosols

Based on currently available evidence, COVID-19 is transmitted when the virus enters the body via the
mucosae (mouth and nose) or conjunctiva (eyes) which can occur through;4
• direct person-to-person contact via saliva and/or mucus,
• respiratory droplets >5-10μm in diameter (e.g. from coughing and sneezing),
• indirect contact from touching infected environmental surfaces/formites and transferring viral
particles to the mucosae or conjunctiva, and;
• smaller (<5μm) respiratory droplets (aerosols).

There is ongoing inquiry regarding the relative contribution of each of the above infection pathways to the
overall spread of the virus. To date, evidence suggests that while possible, the transmission of viral particles
in aerosolised droplets (<5μm) is unlikely to be the most common form of transmission. Evidence for
COVID-19 transmission is continually evolving particularly around the potential for ‘airborne’ transmission.7

It is important to recognise that both large and smaller droplets travel through the air and may be
considered ‘airborne’, however smaller droplets behave differently to larger droplets as they are lighter,
more buoyant, and evaporate more quickly. The science regarding the airborne transmission of disease is
itself complex and equivocal. Questions remain regarding virology (i.e. what amount of a virus is enough to
cause an infection?) and biophysics (i.e. how do particles move in the air under different conditions?).8 The
SARS-CoV-2 may be found in small, aerosolised particles,9 but the extent to which these smaller particles
pose an infection risk or how they move in the air under different conditions is currently unconfirmed.8

For further summarised information regarding the transmission of COVID-19 and selection and use
of personal protective equipment (PPE) please see:

Evidence Brief: COVID-19 Modes of Transmission and Infection

Evidence Brief: COVID-19 Personal Protective Equipment

ANMF EVIDENCE BRIEF: COVID-19: Negative pressure rooms | August 14 2020 2

 Aerosol generating procedures

Various clinical procedures can generate aerosolised particles which may lead to risk of infection.4
Generally, these procedures are conducted in intensive care units, COVID-19 dedicated wards, and in
isolation rooms which could be understood as high-risk environments. Exposure to aerosolised particles
may include both those directly undertaking aerosol generating procedures, as well as those in the same
areas where such procedures occur.9 Different jurisdictions around the world have varying guidance
regarding what is classed as an aerosol generating procedure. In Australia, in the context of COVID-19,
aerosol generating procedures are defined under the following categories:6

Instrumentation or surgical procedures on the respiratory tract:

• Insertion or removal of endotracheal tube and related procedures e.g. manual ventilation and open
suctioning of the respiratory tract
• Bronchoscopy and upper airway procedures that involve open suctioning
• Tracheotomy/tracheostomy (insertion, removal, open suctioning)
• Ear-nose-throat, faciomaxillary or transphenoidal surgery; thoracic surgery involving the lung
• Post-mortem procedures involving high speed devices on the respiratory tract
• Intentional or inadvertent disconnection/reconnection of closed ventilator circuit

Other procedures that can generate respiratory aerosols:

• Manual or non-invasive ventilation (NIV): bi-level positive airway pressure ventilation (biPAP);
continuous positive airway pressure ventilation (CPAP)
• Collection of induced sputum
• High flow nasal oxygen
• Upper gastrointestinal instrumentation that involves open suctioning of URT
• Some dental procedures e.g. involving high speed drilling
• Cardiopulmonary resuscitation (CPR)*
Further, the Australian guidance cautions against the use of nebulisers and alternative means of delivering
medication should be used (such as a spacer). Collection of respiratory specimens may also result in aerosol
production including bronchoalveolar lavage and induced sputum for any patient (including asymptomatic)
and any respiratory sample collection procedure with fever, breathlessness and/or severe cough.
Negative pressure rooms

In Australia, negative pressure rooms are one type of isolation room (Class N).10 It is a single room with an
ensuite that is not shared. It is used for patients who require isolation to reduce airborne transmission of
disease. The Australian Government Department of Health recommends that if available, negative pressure
rooms should be used for;6

• Isolation of hospitalised patients with severe acute respiratory symptoms, and/or probable, or
confirmed COVID-19 infection,
• Aerosol generating procedures^ with presenting patients (general practice, hospital, emergency
department, clinic, or pathology collection centre) with acute respiratory symptoms, and/or
suspected, probable, or confirmed COVID-19 infection.
* As an emergency, life-saving procedure special consideration is warranted for CPR and should not be delayed. While a ‘high risk’ procedure in
terms of infection risk, evidence appears equivocal. There is differing guidance regarding the use of contact/droplet precautions versus airborne
precautions, however airborne precautions may provide additional protection.
^ Including collection of induced sputum

ANMF EVIDENCE BRIEF: COVID-19: Negative pressure rooms | August 14 2020 3

 In the absence of a negative pressure room, an empty, well-ventilated room with the door closed should be
used.6 Negative pressure rooms have special seals to prevent inadvertent escape of pathogens, therefore
with no ventilation in the event of sustained power failure; isolation of airborne patients with infectious
conditions becomes a patient safety risk. As determined by the Australasian Health Infrastructure Alliance,
a negative pressure room must include:
• a Type-B hand basin within the room
• self-closing door
• sufficient and appropriate storage for clinical waste
• separate entry doors to allow for movement of the patient in and out of the room.
• an anteroom for use only by staff and visitors.
• an air handling system that operates at a lower pressure with respect to adjacent areas such as the
anteroom and corridor
• exhausted air to the outside in accordance with AS 1668.2 to prevent air recirculation
• an air supply should located on the ceiling above the foot of the bed
• exhaust air to be located at the head of the bed
• air discharge points located as far as possible from air intakes and from where people congregate or
work
• recirculated through HEPA filters if external exhaust is not possible
• provision of a dedicated exhaust system to each room, separate to the common exhaust air system
• connection to the emergency backup power in case of power failure

Intensive care ventilation hoods

Intensive care ventilation hoods, also known as isolation biohazard hoods, personal ventilation hoods and
other similar names are relatively newly developed devices that cover a patient’s head and upper body
with a transparent tent-like barrier creating a protected micro-environment that reduces the potential for
droplets, including smaller aerosolised droplets, to escape into the surrounding environment.11 Groups
around the world have developed various versions of this new technology which in some cases has entered
clinical practice while still undergoing testing.12

Some of these devices use vacuum systems to generate small negative pressure environments where it
may be more suitable to conduct aerosol generating procedures or to house the patient where traditional
negative pressure rooms are unavailable.13 Some authors have expressed concern regarding the use and
safety of these devices, highlighting a number of potential clinical and infection control considerations that
should be considered when using these devices including the risk of infection when using PPE, disruption
of visibility during clinical procedures, and the proper implementation and use of the device.14

ANMF EVIDENCE BRIEF: COVID-19: Negative pressure rooms | August 14 2020 4

 References
1. World Health Organization. Rolling updates on coronavirus disease (COVID-19). 2020. https://www.who.int/
emergencies/diseases/novel-coronavirus-2019/events-as-they-happen (accessed 25 Mar 2020).
2. World Health Organization. Director-General’s remarks at the media briefing on 2019-nCoV on 11 February 2020.
2020. https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-
ncov-on-11-february-2020 (accessed Mar 25 2020).
3. World Health Organization (WHO). WHO Director-General’s opening remarks at the media briefing on COVID-19 -
11 March 2020. 11 Mar 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-
at-the-media-briefing-on-covid-19---11-march-2020 (accessed 10 Jul 2020).
4. World Health Organization (WHO). Scientific Brief: Modes of transmission of virus causing COVID-19:
implications for IPC precaution recommendations. 29 Mar 2020. 29 Mar 2020 2020. https://www.who.int/news-
room/commentaries/detail/modesof-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-
recommendations (accessed 5 Apr 2020).
5. Queensland Health. Interim infection prevention and control guidelines for the management of COVID-19
in healthcare settings Version 1.13. 24 June 2020 2020. https://www.health.qld.gov.au/__data/assets/pdf_
file/0038/939656/qh-covid-19-Infection-control-guidelines.pdf (accessed 14 Aug 2020).
6. Communicable Diseases Network Australia. Coronavirus Disease 2019 (COVID-19) CDNA National Guidelines
for Public Health Units Version 3.7. 12 Aug 2020 2020. https://www1.health.gov.au/internet/main/publishing.nsf/
Content/7A8654A8CB144F5FCA2584F8001F91E2/$File/COVID-19-SoNG-v3.7.pdf (accessed 14 Aug 2020).
7. Buonanno G, Morawska L, Stabile L. Quantitative assessment of the risk of airborne transmission of SARS-
CoV-2 infection: prospective and retrospective applications. medRxiv 2020: 2020.06.01.20118984.
8. Asadi S, Bouvier N, Wexler AS, Ristenpart WD. The coronavirus pandemic and aerosols: Does COVID-19
transmit via expiratory particles? Aerosol Science and Technology 2020; 54(6): 635-8.
9. Guo ZD, Wang ZY, Zhang SF, et al. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome
Coronavirus 2 in Hospital Wards, Wuhan, China, 2020. Emerging infectious diseases 2020; 26(7): 1583-91.
10. Australian Health Infrastructure Alliance. Australasian Health Facility Guidelines Part D - Infection Prevention
and Control. 1 Mar 2016 2016. https://aushfg-prod-com-au.s3.amazonaws.com/Part%20D%20Whole_7_2.pdf
(accessed 14 Aug 2020).
11. Convissar D, Chang CY, Choi WE, Chang MG, Bittner EA. The Vacuum Assisted Negative Pressure Isolation
Hood (VANISH) System: Novel Application of the Stryker Neptune™ Suction Machine to Create COVID-19
Negative Pressure Isolation Environments. Cureus 2020; 12(5): e8126-e.
12. McGain F, Humphries RS, Lee JH, et al. Aerosol generation related to respiratory interventions and the
effectiveness of a personal ventilation hood. Critical care and resuscitation: journal of the Australasian Academy
of Critical Care Medicine 2020.
13. Rajajee V, Williamson CA. Use of a Novel Negative-Pressure Tent During Bedside Tracheostomy in COVID-19
Patients. Neurocrit Care 2020: 1-7.
14. Jain U. Caution Regarding Enclosures for Airway Procedures. Anesth Analg 2020: 10.1213/
ANE.0000000000004983.

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