2010/3/31
衛生署豐原醫院 外科
游朝慶
在1989年，美國國家壓瘡諮詢委員會（NPUAP）第一屆共識會議發展出和前述系統相似的一套四期系統。NPUAP Staging System在過去20年來，一直被廣為使用，其stage I 定義為給予指壓時紅斑不會消失(non-blanchable erythema)，是皮膚潰瘍的前兆，Stage IV定義為全層皮膚缺損並組織壞死侵及肌肉，骨頭。韌帶，關節等，底部沖刷侵襲（undermining，即pocket口袋），瘻管（sinus tract）也許會伴隨發生。此Stage I的定義因為不好在有深色皮膚的患者上所觀察，於1997年被NPUAP修改為完整皮膚上可被觀察到和重壓有關連的變化，如和周邊或對側的皮膚相比，有溫度（較冷或較熱），組織堅實度（較硬或較鬆軟）或感覺（痛，癢）上的改變。壓瘡在顏色較淡的皮膚上看起來是持續地紅，但在有較深顏色的皮膚上，看起來可能是持續地紅，藍，或紫色。
NPUAP自1989年來，每兩年開一次共識會議consensus，並討論當時和壓瘡相關重要的議題。當美國健康照顧政策與研究機構the Agency for Health Care Policy and Research (AHCPR)現在的the Agency for Healthcare Research and Quality (AHRQ)），是美國重要的品質推展機構，AHRQ在90年代所發展的19個臨床準則後來已成為實證指引發展的重要模式），打算於1992年推出壓瘡治療準則時，由於在NPUAP很多成員也在AHCPR裡面服務，因此於1991年3月NPUAP針對AHCPR 要發表的壓瘡預防準則pressure ulcer prevention guideline舉辦一場公開辯論，並將此專題藉著AHCPR推廣到全美，在1993年的第3屆大會中，則是討論AHCPR的治療準則『Treatment of Pressure Ulcers』，其在1994年發表（http://www.npuap.org/positn1.htm） 。因此有人將NPUAP的壓瘡傷口分類說是NPUAP（1989）與AHCPR（1994）共同推出來的分類系統。
NPUAP於1997年第五屆會議時，當時的主題是“Monitoring Pressure Ulcer Healing: An Alternative to Reverse Staging.”並因而推出”PUSH”tool來定量評估壓瘡。在2005年主題為“Merging Missions,”的共識會議上正式討論Deep Tissue Injury (DTI)的病理機轉，並將DTI列進當前的分期系統中的一期（http://www.npuap.org/PDF/Spring_Newsletter.pdf）
歐洲壓瘡諮詢委員會，European Pressure Ulcer Advisory Panel (EPUAP) 也於1999年對於壓瘡發展出另一套四期系統（是grade分級而非NPUAP的stage分期系統），其Grade 1的定義為給予完整皮膚指壓時紅斑不會消失，在有深色皮膚的人，其皮膚的變化可能是變色、熱、腫、或有硬結，Grade 4表示廣泛地破壞，組織壞死，或侵及肌肉、骨頭或其周邊組織，可不伴隨整層皮膚缺損。
2007年2月，美國NPUAP重新定義壓瘡及其分期，包括原有的四個分期再加上兩個期別，深層組織損傷（deep tissue injury，DTI）及不可分期的（unstageable）。自從DTI於2001年被確認出來之後，經過五年的時間才完成新的分期工作。雖然早在1975年，Shea已定義這個期別，並命名為『許多解剖組織缺損』the amount of anatomical tissue loss，這原始的定義是如此令醫師混淆，並導致無法區分會陰旁皮膚炎（即尿布疹）與DTI導致的潰瘍，而產生不正確的分期。
壓瘡2007年NPUAP定義
壓瘡是身體骨頭突出處，因為受到重壓，剪力或摩擦，而導致的皮膚或皮膚下面的脂肪或肌肉組織受損，有很多因素會為導致壓瘡，但這些因素的重要性仍然不明。
目前EPUAP與NPUAP已相互認同彼此的分類，並於2009年共同發表International NPUAP-EPUAP Pressure Ulcer Definition及International Pressure Ulcer Classification System（以下取自於http://www.epuap.org/）
International NPUAP-EPUAP Pressure Ulcer Definition國際壓瘡定義
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. 此定義和NPUAP 2007年版差不多，只是拿掉摩擦。
International Pressure Ulcer Classification System國際壓瘡分類系統
過去好幾年來歐洲的EPUAP及美國的NPUAP的成員已經互相討論好幾次關於EPUAP和 NPUAP的pressure ulcer grading/staging systems，由於需要制訂一個全世界共通用的治療與預防準則，故需要一個共通的分類系統，Staging/ grading I到IV代表著壓瘡的進展，但有些人不認同這個詞（stage, grade），我們嘗試去找其他的字來代替，但失敗了，”Category”這個中性字被有些人建議來用，Category（種類）代表著非依等級區別的類別，這讓我們不至於誤用說壓瘡從IV進步到I。然而我們瞭解到，大家早已習慣說―stage‖ 及 ―grade ‖，因此我們提議不管用那個名詞(如stage, grade, 或category)都是可接受以及容易瞭解的，無論如何，此次美歐合作最重要利益在於確認兩者之間對於期別的定義是相同的即使他們被寫為-stage II -grade II-category II，我們都同意壓瘡的四個分期，然而在歐洲無法分期的unclassified/unstageable及深層組織損傷deep tissue injury都被歸類為graded IV，NPUAP同意在準則中將這兩類獨立出來，這個將在比較各國的資料後，在拿來討論。
下面先列出國際壓瘡分類系統針對美國的壓瘡分類補充的原文，看起來和2007年的NPUAP分類差不多，故在下一節一起解釋。
Additional Categories for the USA
Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. . Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Category/Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.
CategoryStage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Additional Categories/Stages for the USA
Unstageable/ Unclassified: Full thickness skin or tissue loss – depth unknown
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
Suspected Deep Tissue Injury – depth unknown
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
參考資料
1. Agency for Health Care Policy and Research(AHCPR)：Pressure Ulcers in Adults：Prediction & Prevention. Wasington DC：U.S. Department of Health Human Services: AHCPR; 1992.
2. http://www.npuap.org/positn1.htm
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