Pertussis (Whooping Cough)

Pertussis, commonly known as whooping cough, is one of the most common vaccine-preventable disease in children under 5 years of age. It is known for its violent, uncontrollable coughing which makes it difficult to breathe, eat, or drink. Review this study guide and learn more about pertussis, its pathophysiology, stages, assessment findings, medical management, and nursing care management.

What is Pertussis?
Pathophysiology
Statistics and Incidences
Clinical Manifestations
Assessment and Diagnostic Findings
Medical Management
- Pharmacological Management
Nursing Management
Practice Quiz: Pertussis (Whooping Cough)
References

What is Pertussis?

Pertussis (whooping cough) is a respiratory tract infection characterized by a paroxysmal cough.

Pertussis was first identified in the 16th century.
In 1906, Bordet isolated the most common causative organism, Bordetella pertussis.
As a result of vaccination, however, the number of cases reported decreased by more than 99% from the 1930s to the 1980s.
The disease is still a significant cause of morbidity and mortality in infants younger than 2 years.

Pathophysiology

Humans are the sole reservoir for B pertussis and B parapertussis.

Bordetella pertussis, a gram-negative pleomorphic bacillus, is the main causative organism for pertussis.
Bordetella pertussis spreads via aerosolized droplets produced by the cough of infected individuals, attaching to and damaging ciliated respiratory epithelium, starting in the nasopharynx and ending primarily in the bronchi and the bronchioles.
A mucopurulent sanguineous exudate forms in the respiratory tract.
This exudate compromises the small airways and predisposes the affected individual to atelectasis, cough, cyanosis, and pneumonia.
Transmission of pertussis can occur through direct face-to-face contact, through sharing of a confined space, or through contact with oral, nasal, or respiratory secretions from an infected source.

Statistics and Incidences

Since the early 1980s, pertussis incidence has cyclically increased, with peaks occurring every 2-5 years.

In 2010, according to the CDC, the US pertussis rate reached 27, 550 cases, with 27 related deaths.
In 2011, according to preliminary statistics from the CDC, adolescents (ages 11-19 years) and adults together accounted for 47% of pertussis cases, while children aged 7-10 years accounted for 18% of cases.
The annual worldwide incidence of pertussis is estimated to be 48.5 million cases, with a mortality rate of nearly 295, 000 deaths per year.
From 2001-2003, females accounted for 54% of pertussis cases in the United States.
From 2001-2003, of patients with pertussis, 23% were younger than 1 year, 12% were aged 1-4 years, 9% were aged 5-9 years, 33% were aged 10-19 years, and 23% were older than 20 years.

Clinical Manifestations

Typically, the incubation period of pertussis ranges from 3-12 days; it is a 6-week disease divided into catarrhal, paroxysmal, and convalescent stages, each lasting 1-2 weeks.

Stage 1- Catarrhal phase. The initial phase includes nasal congestion, rhinorrhea, and sneezing, variably accompanied by low-grade fever, tearing, and conjunctival suffusion; pertussis is most infectious during catarrhal phase, but may remain communicable for 3 or more weeks after the onset of cough.
Stage 2- Paroxysmal phase. Patients in the second phase present with paroxysms of intense coughing lasting up to several minutes; in older infants and toddlers, the paroxysms of coughing occasionally are followed by a loud whoop; posttussive vomiting and turning red with coughing are common in affected children.
Stage 3- Convalescent phase. Patients in the third stage have a chronic cough, which may last for weeks.

Assessment and Diagnostic Findings

The criterion standard for diagnosis of pertussis is isolation of B pertussis in culture.

Chest radiography. Chest radiography may reveal perihilar infiltrates or edema with variable degrees of atelectasis.
Blood work. Leukocytosis with absolute lymphocytosis occurs during the late catarrhal and paroxysmal phases; in infants aged 90 days or younger, early serial monitoring of WBC counts is crucial for identifying risk and determining the prognosis of infants with pertussis.
Cultures. The results of blood culture are uniformly negative because B pertussis grows solely in the respiratory epithelium; recovery rates are highest during the catarrhal or early paroxysmal phase and are low after the fourth week of illness.
PCR assay and ELISA. PCR assays and antigen detection are increasingly used to assist in diagnosing pertussis; advantages include greater sensitivity, more rapidly available results, and use later in the disease course; although this or a positive culture is the case definition for reporting pertussis to the CDC or the WHO, some are now recommending confirmation with ELISA before declaring an epidemic.

Medical Management

Supportive therapy is the mainstay of treatment in patients with active pertussis infection.

Hospitalization. Hospitalization should be strongly considered for patients at risk for severe disease and complications.
Diet. No special diet is indicated, although a clinically age-appropriate diet should be maintained.
Activity. Activity for patients with pertussis should be guided by clinical course; in general, patients engage in activity as tolerated.
Monitoring. Most patients older than 1 year can be treated on an outpatient basis if they do not fulfill the criteria for hospital admission.

Pharmacological Management

Antimicrobial agents given during the catarrhal phase may ameliorate the disease.

Antibiotics. The Committee on Infectious Disease (COID) of the American Academy of Pediatrics currently recommends promptly treating all household and other close contacts with erythromycin to limit secondary transmission
Vaccines, inactivated, bacterial. Active immunization increases resistance to infection; vaccines consists of microorganisms or cellular components that act as antigens.

Nursing Management

Nursing management of a patient with pertussis include the following:

Nursing Assessment

Continuous assessment is necessary in order to know possible problems that may have led to concerns that may occur during nursing care.

• Airway patency. Maintaining patent airway is always the first priority.
• Auscultation. Auscultate lungs for presence of normal or adventitious breath sounds.
• Respirations. Assess respirations, note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis are:

• Ineffective airway clearance related to copious and tenacious bronchial secretions.
• Impaired breathing pattern related to decreased airway patency.

Nursing Care Planning and Goals

The major nursing care planning goals for pertussis:

Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
Patient will demonstrate increased air exchange.
Patient will classify methods to enhance secretion removal.
Patient will recognize the significance of changes in sputum to include color, character, amount, and odor.
Patient will identify and avoid specific factors that inhibit effective airway clearance.

Nursing Intervention

The nursing interventions for a patient with pertussis include:

Educate about coughing and breathing. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession).
Promote effective coughing. Educate the patient about optimal positioning (sitting position), use of pillow or hand splints when coughing, use of abdominal muscles for more forceful cough, use of quad and huff techniques, use of incentive spirometry, and importance of ambulation and frequent position changes.
Educate about proper positioning. Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed.
Encourage increase in oral fluid. Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function.
Administer medications as prescribed. Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects.
Provide chest physiotherapy. Provide postural drainage, percussion, and vibration as ordered.

Evaluation

Goals are met as evidenced by:

Patient maintained clear, open airways as evidenced by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
Patient demonstrated increased air exchange.
Patient classified methods to enhance secretion removal.
Patient recognized the significance of changes in sputum to include color, character, amount, and odor.
Patient identified and avoided specific factors that inhibit effective airway clearance.

Documentation Guidelines

Doumentation in a patient with pertussis include:

Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
Cultural and religious beliefs, and expectations.
Plan of care.
Teaching plan.
Responses to interventions, teaching, and actions performed.
Attainment or progress toward the desired outcome.

Practice Quiz: Pertussis (Whooping Cough)

Nursing practice questions for Pertussis (Whooping Cough). Please visit our nursing test bank page for more NCLEX practice questions.

1. Nurse Sandra is handling a child with pertussis. During the assessment, the nurse will observed on which of the following characteristic of the child’s cough?

A. A sour cough
B. A chesty cough
C. A hacking cough that ends with a whooping sound
D. A barking, painful cough

1. Answer: C. A hacking cough that ends with a whooping sound

Option C: A whooping cough sounds like a severe, hacking cough that ends with a whooping sound as the patient gasp for breath.
Option A: A cough with a sour taste is usually a sign of GERD (gastroesophageal reflux disease).
Option B: Chesty cough, also called a wet cough, occurs when an individual tries to coughs up mucus and is seen to patients with pneumonia and bronchitis.
Option D: A barking painful cough that sounds like a seal is usually found on children with croup.

2. A clinical instructor is providing teachings among nursing students about the stages of pertussis. Which of the following is the final phase of a pertussis infection?

A. Paroxysmal phase
B. Recovery phase
C. Catarrhal phase
D. Convalescent phase

2. Answer: D. Convalescent phase

Option D: The final phase of a pertussis infection is known as the convalescent phase. This usually lasts 2–6 weeks where coughing becomes milder and less frequent.

3. The recommended antimicrobial agents for chemoprophylaxis or treatment of Whooping cough (Pertussis) are EXCEPT

A. Amantadine (Symmetrel)
B. Erythromycin (Erythrocin)
C. Trimethoprim-sulfamethoxazole (Septra)
D. Azithromycin (Zithromax Tri-Pak)

3. Answer: A. Amantadine (Symmetrel)

Option A: Pertussis is a highly contagious and serious infection that is caused by a bacterium so an antiviral agent (Amantadine) will not be effective.
Option B & D: Macrolides such as erythromycin and azithromycin are the drug of choice for pertussis in children 1 month of age and older.
Option C: Trimethoprim-sulfamethoxazole, an anti-bacterial sulfonamide is an alternative drug to macrolides for patients with pertussis ages 2 months and older.

4. Which of the following statements are true about Pertussis? Select all that apply.

A. Pertussis (Whooping cough) is caused by the bacteria Bordetella pertussis.
B. Tdap, a combination vaccine given as a protection against tetanus, diphtheria and pertussis.
C. Infected individuals are most contagious up to about 2 weeks after the cough begins.
D. Infants under six months of age are require for home care monitoring.
E. Early symptoms of the disease (runny nose, low-grade fever, and a mild, occasional cough) can last for 1 to 2 weeks.

4. Answer: A, B, C, and E.

Option D: Infants under 6 months who are diagnosed with pertussis requires hospitalization to carefully observe and treat for possible respiratory complications such as apnea, cyanosis, or hypoxia.

5. A pregnant woman went to a community clinic to ask a health care provider about Dtap vaccination. Which of the following statements made by the HCP is true about the vaccine, except?

A. After receiving a Tdap vaccine, the mother’s body will create antibodies and passes some of them to the baby prior to birth.
B. If Tdap is administered before pregnancy, it should not be repeated between 27 and 36 weeks gestation.
C. A single dose of Tdap vaccine will provide enough protection on the succeeding pregnancy.
D. All women can receive a Tdap vaccine during the 27th through the 36th week of pregnancy.

5. Answer: C. A single dose of Tdap vaccine will provide enough protection on the succeeding pregnancy.

Option C: It is recommended to get a Tdap vaccine during each pregnancy since the amount of pertussis antibodies in the body decreases over time.
Options A, B, and D: These are accurate statements about Tdap vaccine during pregnancy.

References

Sources and references for this study guide for polio:

Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the committee on infectious diseases (No. Ed. 31). American academy of pediatrics.
Oshinsky, D. M. (2005). Polio: an American story. Oxford University Press. [Link]
Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]