Pertussis Basics for Nursing Students

Pertussis (also known as “whooping cough”) is a respiratory tract infection caused by the bacteria Bordetella pertussis. It is a highly contagious disease that predominantly impacts children. 

Pertussis is spread via droplets in the air when an infected individual breathes or coughs. Because cases of pertussis increase approximately every three to four years, it is considered a cyclical disease. The infection consists of four stages that typically occur over six to ten weeks, though this may vary. 

Four stages of pertussis

• Colonization stage (1 week) – In this stage, bacteria attach to the cilia and begin replication. During this stage, the individual may have no symptoms but is still able to spread the disease to others.
• Catarrhal stage (1 to 2 weeks) – During this stage of infection, the bacteria proliferate, which results in excess mucus production and inflammation. The individual begins to have symptoms such as a runny nose, mild cough and low-grade fever. 
• Paroxysmal stage (2 to 3 months) – This stage is characterized by the distinctive cough that occurs in pertussis. These coughing spells (paroxysms) can last for over a minute each with gasps for air in between coughs. This inspiratory gasp for air creates the distinctive “whooping” sound associated with this condition, though this is less likely to occur in infants. These coughing spells can be so severe that they lead to vomiting, exhaustion, and dehydration.
• Convalescent stage (varies, can last weeks to months) – This stage is marked by a noticeable decrease in severity of the cough. Over time the cough improves and the individual begins to feel better. 

Note that transmission of pertussis occurs during the colonization and catarrhal stage through the first two to three weeks of the paroxysmal stage.

The pertussis vaccine

Prior to the development of a vaccine, pertussis was considered a common illness that everyone contracted during childhood, even though it could cause serious illness and even death. The first pertussis vaccine was developed in the 1930s and used widely in the U.S. by the mid-1940s. Cases of pertussis dropped from about 200,000 a year to a low of around 1,000 cases in the mid-1970’s. 

Unfortunately, pertussis cases have increased since the 1980’s and outbreaks of the disease have even reached epidemic levels in some states. In 2019, more than 15,000 cases and nine deaths were reported to the CDC.

Currently the pertussis vaccine is combined with vaccines for diphtheria and tetanus in what is commonly referred to as the DTaP vaccine, which is intended for children under the age of 7. Older children and adults receive a similar vaccine called the Tdap, which simply has smaller amounts of vaccine against diphtheria and whooping cough.

The vaccine for pertussis is an “acellular” vaccine, meaning the viral cells in the vaccine are dead. The key advantage of this type of vaccine is fewer side effects without compromising on strength of immunity. Note that the pertussis vaccine does not provide lifelong immunity against the disease, but is instead intended to protect children during their most vulnerable years.

In addition to children, the vaccine is also administered to pregnant women to help protect the child from pertussis during infancy, since the first vaccine is not administered until the child is 2 months of age. Four additional doses are administered at 4 months, 6 months, between 15 and 18 months, and a final dose between 4 to 6 years old.

If a vaccinated individual does contract pertussis, the evidence shows that the disease stages are shorter, especially in those who have completed the full schedule of vaccinations.

Who is most at risk for pertussis?

Individuals most at risk for contracting the disease include infants, partially vaccinated and unvaccinated children, unvaccinated teens and adults, those with underlying respiratory conditions such as asthma or cystic fibrosis. Additionally, females are affected more than males.

What are the complications of pertussis?

Infants tend to have the most severe complications and most severe illness. The most common childhood complication is bacterial pneumonia. Other rare, but serious complications include seizures, cerebral edema and inflammation, and even death.

The complications in adults are more widespread and include hearing loss, scleral hemorrhage, urinary incontinence, inguinal hernia, cracked ribs, and pneumonia. Serious complications in adults include pneumothorax and carotid artery dissection. Anyone with an underlying respiratory disorder is more likely to have serious complications, especially those with cystic fibrosis.

Pertussis: Straight A Nursing LATTE method

Now that you have a baseline understanding of pertussis, let’s go through the nursing implications using the Straight A Nursing LATTE method.

L: How does the patient LOOK?

The initial symptoms arise approximately 7 – 10 days after infection and include runny nose, nasal congestion, red and watery eyes, and fever. The patient may have a cough at this time, but it does not yet have the characteristic “whoop” that is associated with the disease. At this stage, the individual appears to have a common cold.

As the condition progresses, symptoms become more severe and include prolonged coughing attacks that may have the characteristic “whooping” sound as the individual gasps for air.  Additional symptoms are fatigue and even a red or blue-ish face due to decreased oxygen during coughing attacks. Note that infants may not cough at all, but instead have periods of apnea. 

A: How do you ASSESS the patient?

The key assessments you will conduct for a patient with pertussis are related to their respiratory status.

• Observe the patient for signs of respiratory distress. Signs of severe respiratory distress in small children include nasal flaring, grunting, and use of accessory muscles. A child displaying these signs needs immediate intervention. Click here to learn more about pediatric respiratory distress. 
• Auscultate lungs to observe for adventitious sounds, which can occur with pneumonia (a common complication) and to observe for diminished airflow, which can occur with pneumothorax and airway occlusion.
• Assess airway patency since the inflammation and mucus associated with pertussis could lead to partial or complete airway occlusion. 
• Measure oxygen saturation levels and count respirations.
• If available, utilize end-tidal CO2 monitoring to catch oxygenation issues before they show on pulse oximetry. 

Other important assessments include monitoring for fever, decreased oral intake, and dehydration. 

T: What TESTS will be ordered? 

Culture is the gold standard test for diagnosing pertussis, but one drawback is that it takes longer than other diagnostics. Other tests include serology and PCR. One challenge with pertussis testing is obtaining the sample via a nasopharyngeal swab, which can be difficult in infants and children. 

Other tests include:

• WBC will be elevated in infection
• Chest x-ray to assess for complications such as pneumonia or even pneumothorax in severe cases.
• Pulmonary function test to determine the effect pertussis has had on lung function

T: What TREATMENTS will be provided? 

Studies show that antibiotics are most effective in the early stages of the disease, and may have no effect if started in later stages. Not only do they shorten the duration of illness, but can reduce the risk of transmission. In most cases, the patient will not transmit the disease after five full days of appropriate antibiotic treatment. Commonly used antibiotics are azithromycin and erythromycin.

Unfortunately traditional cough medicines do not lessen the frequency or severity of the cough associated with pertussis and their use is discouraged. Additionally, studies have shown that the use of corticosteroids, bronchodilators, and antihistamines have not proven to be beneficial. However,  you may still see these medications used, specifically inhaled beta-agonists in children with respiratory compromise.

Other treatments include: 

• Ensuring adequate hydration and nutrition as children experiencing the intense coughing of pertussis will have increased fluid and caloric requirements, especially if the coughing induces vomiting. In some cases, this involves IV hydration and enteral feeding.
• Take measures to prevent coughing such as decreasing stimulation and providing cool-mist humidification in the room.
• Critically ill infants and children will require advanced interventions that will vary based on their specific complications, but can include anti-seizure medications, mechanical ventilation, exchange transfusion (which involves removing the patient’s blood and replacing it with donor blood), and even ECMO.
• During a coughing spell, encourage the patient to sit upright as this can help facilitate breathing. 

E: How do you EDUCATE the patient and/or family?

Education regarding the care of infants with pertussis includes:

• Infants should be kept in a dark and quiet room in order to decrease stimulation and prevent severe coughing fits. 
• Focus on small frequent meals to increase nutritional intake. 
• Monitor for signs of dehydration, which include sunken eyes, sunken fontanelle, lack of tears when crying, reduced number of wet diapers, and lethargy.
• Cough medications and expectorants are not advised.
• Teach the signs of respiratory distress in infants, which include nasal flaring, grunting and use of accessory muscles.

General education includes: 

• Proper hand hygiene is an essential and important way to stop the spread of disease.
• If antibiotics are prescribed, individuals need to stay isolated for five days. If no antibiotics have been prescribed, individuals are infectious for 3 weeks.
• Take the full course of antibiotic medications even after starting to feel better. 

• Convey the importance of receiving vaccines for those who are around vulnerable populations (specifically those with close contact with infants).
• Sitting upright helps make breathing easier during coughing fits.
• Use of a cool-mist humidifier can help ease coughing; do not use steam.
• Avoid irritating substances such as smoke which can make coughing worse.
• Seek immediate emergency treatment if any of the following occurs: Face turns red or blue, if you pass out coughing, if you stop breathing, or if you feel fatigued / are sleeping too much. (Elsevier, 2022). 

If you found this helpful, dive into more pediatric topics here.

Take this topic on the go by tuning in to episode 295 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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