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Ventilation Requirements - Bronchoscopy Procedure Room Requirements

What are the ventilation requirements for rooms where bronchoscopy procedures are performed ?

Any examples are for illustrative purposes only.

The performance of a bronchoscopy procedure in a negative pressure room is a requirement established by ASHRAE 170-2008 ventilation table 7.1.  This space provision has been determined by NFPA Code and as such an organization cannot risk assess out of a code requirement. 

Recognizing that there are extenuating patient specific circumstances that may arise that would preclude a bronchoscopy from being performed in a space specifically designed for that purpose, an established process must be in place in the event the situation arises. These circumstances may include but are not limited to scenarios where patient safety concerns take precedence (e.g., due to immediacy of the procedure, inability to move the patient safely, etc.) or the need to perform the procedure along with other critical procedures in a positive pressure environment such as the Operating Room. 

The organization's process must address items such as, but not limited to:
  • The patient has been evaluated to determine the need to perform the bronchoscopy in a non-controlled environment
  • The risks associated with unique situations where the need exists for performing bronchoscopies in an alternative location were evaluated, including specific patient risk factors (e.g., evaluation of the patient for a diagnosis of airborne communicable disease as a part of their differential diagnosis)
  • Interventions and activities designed to mitigate the risks identified (e.g., the use of a HEPA unit to scrub the air space if indicated, scheduling the patient in the OR at the end of the day, etc.)
Additional Resources:
Hierarchical Approach to Infection Control Standards
Manual: Hospital and Hospital Clinics
Chapter: Infection Prevention and Control IC
New or updated requirements last added: May 22, 2024. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: May 22, 2024 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on May 22, 2024 with update notes of: Reflects new or updated requirements Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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