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Japanese Journal of Comprehensive Rehabilitation Science (2020)

Case Report

A case of acute aortic dissection with successful return to normal daily
life following severe acute respiratory distress syndrome throughcontinuous rehabilitation from the acute stage to the convalescent stage
Naonori Tashiro, RPT, PhD,1,2 Tokutada Sato, MD, PhD,3 Hiroshi Suzuki, MD, PhD,3
Fumihito Kasai, MD, PhD4
Department of Physical Therapy, School of Nursing and Rehabilitation Sciences, Showa University, Yokohama,
Kanagawa, Japan2
Rehabilitation Center, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Kanagawa, Japan3
Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
4
Department of Rehabilitation Medicine, Showa University, Shinagawa-ku, Tokyo, Japan1

ABSTRACT
Tashiro N, Sato T, Suzuki H, Kasai F. A case of acuteaortic dissection with successful return to normal daily
life following severe acute respiratory distresssyndrome through continuous rehabilitation from theacute stage to the convalescent stage. Jpn J Compr
Rehabil Sci 2020; 11: 116-120.
A 70-year-old male with back pain presented to thehospital for Stanford type B acute aortic dissection.
Treatment was initiated using rest and a combinationof antihypertensive drugs and analgesics. On day 2of hospital stay, he developed hypoxemia and wasdiagnosed with acute respiratory distress syndrome(ARDS). On day 4 of hospital stay, PaO2/FiO2 (P/F
ratio) of 124.7 indicated persistence of hypoxemia andphysical therapy was initiated. Prone positioning
therapy for 11―16 hours per day was performed
continuously for four days. On day 7, his P/F ratio wasmaintained at ≥300. Image findings also indicatedimprovement. On day 10, he was weaned off theventilator and began meals and ambulation. On day
12, his grip strength (right/left) was 26.8/25.5 kg,
quadriceps muscle strength (right/left) was
0.22/0.19 kgf/kg, Medical Research Council (MRC)score was 56, and Functional Status Score for the
Intensive Care Unit (FSS-ICU) was 28. He wastherefore discharged from the ICU. His exercise load
was gradually increased in stages while maintaining
Correspondence: Naonori Tashiro, RPT, PhD
Rehabilitation Center, Showa University Fujigaoka
Rehabilitation Hospital, 2―1―1 Fujigaoka, Aoba-ku,
Yokohama, Kanagawa 227―8518, Japan.
E-mail: tashiro@cmed.showa-u.ac.jp
Accepted: August 28, 2020
Conflict of interest: The authors have no conflicts of interest
directly relevant to the content of this article.
©Kaifukuki Rehabilitation Ward Association 2020
doi.org/10.11336/jjcrs.11.116

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his systolic blood pressure at ≤140 mmHg. On day 37,
he was able to walk with a cane and ascend/descendstairs. Therefore, he was transferred to the rehabilitation
hospital. On day 65 of hospital stay, he was able towalk and stand without mechanical assistance. His
grip strength was 34.0/33.0 kg, quadriceps muscle
strength was 0.48/0.49 kgf/kg, MRC score was 60,
FSS-ICU score was 35, and six-minute walking
distance was 342 m, indicating satisfactory recovery
of functions, and therefore he was discharged home.
Key words: acute respiratory distress syndrome, acuteaortic dissection, rehabilitation, return to normal daily
life
Introduction
The mortality rate of acute respiratory distresssyndrome (ARDS) has gradually been on the decline
because of advances in medical technology [1];however, the rate of successful return to normal daily
life among survivors is low and their quality of life
(QOL) is also low. Long-term ventilator managementof severe respiratory failure causes respiratory
dysfunction and disorders of motor, cognitive andmental functions. Such problems persist even after
discharge from the ICU. This so-called Post-Intensive
Care Syndrome (PICS) has an effect on QOL. Recently,
therapeutic outcomes for ARDS have shown that, in
addition to the short-term survival rate, a shift towards
effectiveness in long-term vital prognosis andfunctional recovery has also occurred.
In the present case, the patient suffered severe
ARDS comorbidity with Stanford type B acute aortic
dissection, and therefore required long-term ventilator
management. Owing to the continuous rehabilitation
performed in the ICU from the acute stage to theconvalescent stage, the patient showed satisfactory
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Tashiro N et al.: Acute aortic dissection following ARDS

functional improvement, which eventually allowed his
return to normal daily living.
Consent to publish this data was obtained from thepatient after providing a detailed description of thisreport.
Case
Case: A 70-year-old male, height 177 cm, weight
68.7 kg.
Medical history: At age 37, he underwent
pharmacotherapy for acute pancreatitis; at 40, he
underwent surgery for rupture of an Achilles tendon;at 47, he underwent surgery and pharmacotherapy forchronic recurrent otitis media. Since age 69, he has
been undergoing outpatient treatment at a local
hospital for hypertension.
History of current illness: After retirement he lived
independently. While playing mahjong near his residence,
he experienced sudden back pain and was transported toan acute-care hospital on an emergency basis.
Findings upon arrival at the hospital: He was conscious
and alert upon arrival. Blood pressure (BP) was
170/86 mmHg, heart rate was 70 bpm, respiratory rate
was 20 breaths/min, and arterial blood gas analysis
while wearing an oxygen mask (10 L/min) showed pH
7.415, PaCO2 38.8 mmHg, PaO2 166.8 mmHg, and−HCO3 24.3 mEq/L. CT findings indicated an invasive
shadow in the left lung field and early-stage thrombosedtype aortic dissection from the origin of the leftsubclavian artery to superior to the renal artery branch.
Post-admission course: Based on the test findings,
the patient was diagnosed with Stanford type B acuteaortic dissection. A treatment course was initiated,which comprised rest, antihypertensive drugs, andanalgesics. On day 2 of hospital stay PaO2/FiO2 (P/F
ratio) was 108, indicating rapid onset hypoxemia.
Non-invasive positive-pressure ventilation therapy
was performed, but on day 3, his P/F ratio was 75.1,
which indicated no improvement. In addition toelevated inflammatory response as indicated by CRP
of 23 mg/dL, a chest radiograph showed diffuse
invasive shadows mainly in the bilateral hilar regions
Therefore, he was diagnosed with ARDS and placedon ventilation management. On day 4, the P/F ratio
was 124.7, indicating little improvement in the
hypoxemia. Consequently, range of motion (ROM)training and airway clearance therapy were initiated,which comprised prone positioning therapy andmanual respiratory assistance procedures. His firstprone positioning therapy session lasted three hours.
He placed his face, anterior chest, pelvis, and knees
on a memory foam urethane mat. He underwent
depressurization each hour, and he changed his
position every two hours. During this period, he was
examined for skin problems such as pressure ulcers.
His P/F ratio changed from 124.7 to 344.3, indicating
immediate improvement in oxygenation. His systolic

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BP decreased from 105 to 103 mmHg, mean
pulmonary arterial pressure decreased from 30 to
25 mmHg, and cardiac output increased from 4.6 to
5.6 L/min (Table 1). For the next four days, heunderwent at least 11 hours per day of prone positioning
therapy, which improved his P/F ratio to at least 300
and his image findings. Therefore, prone positioning
therapy was discontinued on day 7 of hospital stay(Figure 1). During prone positioning therapy, no
adverse events, such as progression of the aortic
dissection, skin trouble, or tube trouble, were observed.
On day 10, he was weaned off the ventilator, and began
meals and ambulation. His subsequent course is shownin Table 2. On day 12 of hospital stay, his grip strength(right/left) was 26.8/25.5 kg, quadriceps muscle
strength (r/l) measured using a handheld dynamometer
was 0.22/0.19 kgf/kg, Medical Research Council(MRC) score was 56, Functional Status Score for the
Intensive Care Unit (FSS-ICU) was 28, indicating
recovery of motor functions, and Barthel Index score
was 45. Therefore, he was discharged from the ICU.
Subsequently, his exercise load was gradually
increased in stages to maintain his systolic BP at≤140 mmHg to expand his activities of daily living(ADL). On day 37, he was able to walk with a cane
and ascend/descend stairs, grip strength (r/l) was
32.0/30.4 kg, quadriceps muscle strength (r/l) was
0.39/0.38 kgf/kg, MRC score was 60, FSS-ICU score
was 33, and Barthel Index score was 100, all showing
improvement. The patient expressed a desire to further
improve his physical functions; therefore, on day 37,
he was transferred to a rehabilitation hospital where heunderwent the following physical therapy continuously
at two sets/day: muscle strengthening, balance
training, walking training, and ADL training. A
cardiopulmonary exercise test performed on day 46
showed that his peak VO2 was 16.6 mL/min/kg andexercise tolerance predicted value decreased to 72%.
Thus, he began aerobic exercise with the target set at
an anaerobic threshold of heart rate at 71 bpm. On day
65 he was able to stand without mechanical assistanceand walk; his grip strength (r/l) was 34.0/33.0 kg,
quadriceps muscle strength (r/l) was 0.48/0.49 kgf/kg,
MRC score was 60, FSS-ICU score was 35, and sixminute walking distance was 342 m, all of whichshowed improvement. His ADL was rated at a Barthel
Index score of 100, and therefore he was discharged
home. After discharge, he was able to use public
transport when making outpatient visits to this
hospital.
Discussion
Acute aortic dissection is reportedly associated withsudden worsening oxygenation two or three days after
onset, regardless of whether respiratory status waspreserved immediately after onset [2]. Possible
explanations for this include inflammatory response
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Tashiro N et al.: Acute aortic dissection following ARDS

Table 1. Cardiopulmonary parameters at pre and post prone position (on day 4).
Pre prone position

Post prone position

TV (mL)

650

750

RR (bpm)

12

12

pH

7.415

7.423

PaCO2 (mmHg)

43

42.5

PaO2 (mmHg)

74.8

206.6

−

HCO3 (mEq/L)

27

27.1

P/F ratio

124.7

344.3

Lac (mmol/L)

1.11

1.15

SvO2 (％)

76

79

HR (bpm)

115

110

105/68/80

103/65/78

PCWP (mmHg)

16

16

mPAP (mmHg)

30

25

RAP (mmHg)

25

10

CO (L/min)

4.6

5.6

2.4

2.6

SVR (dyn･sec/cm )

1,515

1,425

SVRI (dyn･sec･m2/cm5)

2,757

2,622

Noradrenaline (μg/kg/min)

0.1

0.1

DOB (μg/kg/min)3

3

Dexmedetomidine (μg/kg/h)

0.1

0.2

Fentanyl (μg/kg/h)

0.5

1.4

BP (s/d/m) (mmHg)

CI (L/min/m2)
5

TV, tidal volume; RR, respiratory rate; SvO2, venous oxygen saturation; PCWP,
pulmonary artery wedge pressure; mPAP, mean pulmonary artery pressure; RAP,
right atrial pressure; CO, cardiac output; CI, cardiac index; SVR, systemic vascular
resistance; SVRI, systemic vascular resistance index; Lac, lactate; DOB, dobutamine.
caused by damage to the vascular endothelium and thesmooth muscle, the appearance of pleural effusion,and atelectasis due to bed rest; however, the exact
mechanism remains unknown. In the present case, on
day 2 of hospital stay the patient was found to havebeen suffering from sudden hypoxemia due to ARDS;
therefore, we considered prone positioning therapy.
Although this was a case of early-stage thrombosedtype aortic dissection, rest and antihypertensive
treatment led to hemodynamic stabilization. Since thesubjects in the PROSEVA study [3] conducted by
Guérin et al. had the same respiratory status as thepresent case, we decided to perform prone positioning
therapy. As a result, we achieved marked improvementin oxygenation, and the patient was able to maintainnormal hemodynamic status while pulmonary arterialpressure decreased and cardiac output increased.
Regarding the improvement in oxygenation, as
previously reported [4, 5], the prone position reopens
the dorsal alveoli, decreases intra-alveolar watercontent in the dorsal lungs and reduces interstitial
edema, which we believe led to the improvement in
the ventilation/perfusion ratio as a result of the effects
of body position drainage and other factors.
Furthermore, Jozwiak et al. reported that changes in
hemodynamics achieved as a result of prone
positioning therapy were not significant changes inheart rate and BP, but rather increases in cardiac output
in cases of decreased pulmonary vascular resistance[6]. In the present case, we observed decreased

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(a)

(d)

(c)

(b)

(e)

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(f)

Figure 1. Chest radiography and CT findings.
(a) and (d) On day 3 after admission (pre prone position), (b) and (e) On day 6 after admission (prone
position phase), (c) and (f) On day 13 after admission (post prone position).
Table 2. Summary of the clinical course.

MRC; Medical Research Council, FSS-ICU; Functional Status Score for the Intensive Care Unit.
pulmonary arterial pressure, and the dilated pulmonary
arteries and resulting decrease in pulmonary vascular
resistance associated with improved oxygenation andthe increase in the pulmonary vascular bed resulting
from the improvement in the ventilation/perfusion
ratio alleviated the afterload on the right ventricle,
which we believe led to the increased cardiac output.


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The present case had severe ARDS that required
long-term artificial ventilator management over eightdays, but intervention in the form of rehabilitation led
to an MRC score of 56 and an FSS-ICU score of 28 at
the time of discharge from the ICU and an MRC scoreof 60 and FSS-ICU score of 33 at hospital discharge,
indicating recovery of satisfactory motor functions.
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Tashiro N et al.: Acute aortic dissection following ARDS

The MRC score is an index of muscle strength in threemuscle groups in each of the four extremities. The
maximum total score for all four extremities is 60,
and a score of <48, which indicates diffuse muscle
weakness, is used as screening for ICU-acquired
weakness (ICU-AW). The FSS-ICU is an evaluativeindex of movement capacity and is comprised of fivebasic movements: rolling over in bed, sitting up in
bed, maintaining a seated position at the edge of thebed, standing up, and walking. Cases that are able toprogress from an acute-care hospital to discharge tohome are reported to have an FSS-ICU score of 19
within four days of hospital admission and a score of
28 at discharge [7]. The present case was able to avoid
ICU-AW and at discharge from the ICU his FSS-ICU
score was higher than 28, which is used as a rule-ofthumb for determining fitness for discharge to home[7]. However, on his detailed muscle strength
evaluation using instrumentation, he did not achieve
the minimum of 0.43 kgf/kg in quadriceps muscle
strength that is required for independent walking in thehospital [8]. Thus, points were deducted from his
walking score on the FSS-ICU at discharge, and herequired continuous physical therapy at a rehabilitation
hospital. On day 65 after disease onset, his scores formuscle strength, basic movement capacity, andexercise tolerance had improved markedly, enabling
him to return to normal daily life. A study on the motor
functions of ARDS patients [9] reported that the sixminute walking distance score after three months wasa median of 281 m, which was a recovery of 49% of
the predicted value. In the present case, 65 days after
disease onset, the score improved to 342 m, indicating
he had made remarkably good progress. Aggressive
and comprehensive rehabilitation intervention after apatient moves out of the acute stage can be expected toresult in improvement in the functional prognosis ofsevere ARDS patients. Even in cases of severe ARDS
that require acute-stage treatment, continuous
treatment planning designed to support patient
improvement from the acute stage to return to normal
daily life is required.
Conclusion
We experienced a case in which continuous

rehabilitation from the acute stage to the convalescentstage was provided. The patient was suffering from
Stanford type B acute aortic dissection with ARDS
comorbidity that required artificial ventilation.
Management led to improvement in functional
prognosis and allowed the patient to return to normal
daily life. In cases of severe ARDS, aggressive andcontinuous rehabilitation from the acute stage to theconvalescent stage is required.

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