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Breathe Easy: The Advent of CPAP by David K. Randall

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by David K. Randall

This is the tale of how an Australian man with a vacuum cleaner fixed a mistake in evolution. It begins in the late 1970s. Colin Sullivan is a physician in the Respiratory Unit at Sydney's Royal Prince Alfred Hospital. There, he treats patients who have problems breathing. The most common complaint, by far, is snoring. Sullivan knows better than most doctors in his field that snoring is often a sign of a serious disorder known as sleep apnea. The disorder had been identified only about a decade earlier. Patients with sleep apnea experience a strange nightly sensation that brings the body disturbingly close to death. As if on a seesaw, the lack of air causes the oxygen levels in the blood to plummet and the blood pressure to jump. And for some patients, the heart stops beating for almost ten seconds at a time.

Eventually, the brain gets the urgent message that the body is choking. The brain jolts awake, and the body instinctively gasps for air. Yet as soon as the airway is clear, the brain immediately falls back to sleep. That's when the cycle starts again. It is all so quick that it can happen more than twenty times an hour, all night long, without the sleeper remembering it the next day. Someone lying next to him or her, however, can hear this process at work: when the rhythmic sawing of a snorer's breath pauses and then becomes a hard ghhackghhack- ghhack, it's most likely the body frantically clearing its airway.

Patients with mild cases of sleep apnea complain of constant exhaustion, a result of never spending more than a few minutes asleep at a time. Severe cases can be life-threatening. A 1992 report by the National Commission on Sleep Disorders estimated that sleep apnea was the cause of 38,000 fatal heart attacks and strokes in the United States each year.

Sleep apnea was discovered when a group of American physicians noticed that some obese patients complained of overwhelming fatigue and would drift asleep unintentionally. With a literary flourish, they named the condition Pickwickian syndrome after a character in Charles Dickens's first novel, The Pickwick Papers, who falls asleep standing up. Doctors incorrectly attributed the sleepiness to a combination of excess weight and abnormally high levels of carbon dioxide in the blood. It was only later that science understood sleep apnea to be a common breathing disorder caused by the position of the tongue and tissues of the throat. It was then given the name apnea, from the Greek word for breathless.

Sleep apnea was on the frontier of sleep medicine in the late 1970s. Sullivan had recently returned from a fellowship in Toronto, where he spent three years studying the breathing patterns of dogs while they slept. English bulldogs, pugs, and other breeds with pushed-in faces are the only animals besides humans that experience sleep apnea. The years spent working with dogs gave Sullivan an idea. Once back in Sydney, he devised a mask that fit over a dog's snout. The mask continuously pumped in air from the surrounding room, increasing the air pressure in the throat and preventing it from closing up. Experiments with dogs suggested that the steady flow of air dramatically improved sleep. All Sullivan needed was a human to try it out on.

In June of 1980, he found one. A man walked into the hospital with such a severe case of sleep apnea that Sullivan recommended an immediate tracheotomy. The patient refused the tracheotomy, but he was happy to volunteer as a test patient for Sullivan's air-pressure machine. Sullivan built a test model that afternoon. He grabbed the engine out of a vacuum cleaner and attached it to a handful of plastic tubes. He then took a diving mask and coated the edges with a silicone sealant that prevented air from leaking out of it. Soon, he had a system that allowed him to pump air through the mask at a controlled pressure. The patient was hooked up to the monitors, put on the mask and fell asleep almost instantly. He began experiencing sleep apnea within a few minutes. Sullivan then slowly started to increase the pressure in the air flowing through the mask and into the patient's airway. Suddenly, the apnea stopped. The patient began breathing normally. As Sullivan watched in amazement, the patient instantly went into deep REM sleep - a rare phenomenon suggesting that his brain had been starved of restorative sleep. Sullivan then slowly decreased the pressure of the air flowing through the mask. The apnea returned.

Sullivan left the settings on the machine at a level where the patient was free of sleep apnea. Then he waited. For about seven straight hours, the patient was in abnormally intense, deep sleep. When he woke up the next day, he told Sullivan that he felt awake and alert for the first time in years.

Sullivan began searching for other patients willing to serve as guinea pigs. He found five whose long histories of excessive daytime sleepiness and loud snoring seriously affected their lives. One subject, a thirteenyear- old boy, had been classified as mentally retarded after he was unable to stay awake at school. Sullivan observed each patient for three nights in a sleep lab. On the third night, he had each test the mask. Just as with the patient in the hospital, the positive airway pressure prevented their throats from closing while they slept. Patients told him that the improvement in their sleep was life-changing.

But Sullivan's mask wasn't embraced in the medical field as quickly. Many doctors were not convinced that sleep apnea was a serious condition, and even fewer thought that a person would be willing to sleep wearing a mask night after night. One told Sullivan that his machine was nothing more than a money-making fad. Sullivan continued to refine the mask, experimenting with ways to give it a tighter seal on the face without making it more uncomfortable. With the help of an engineer from the University of Sydney, he began crafting masks that featured various shapes of the nose. He experimented with motors to cut down on the noise, pulling one from a paint compressor and another from a different-model vacuum cleaner. Patients began coming to him from all over Australia. By 1985, Sullivan had more than a hundred patients using a continuous positive airway pressure device on a long-term basis.

The next year, Sullivan met a former university professor and fellow Australian named Peter Farrell. At the time, Farrell had recently given up a job studying kidney disorders at the University of Washington to become a business consultant for Baxter International, which by 2011 was a $30 billion health-care company. He was on the lookout for new medical devices. Sullivan said that he had one.

Farrell asked to talk with patients who were using the machine. They told him that they slept with it every night despite the drawbacks, chief among them being the noise. The machine still ran off of a vacuum-cleaner engine, creating a whirl so loud that one tester told Farrell that he had cut a hole in his bedroom wall so he could leave the base of the machine in the next room. Another patient who met with Farrell had bruises in an oval pattern over his face from the suction caused by the mask, but still wore it every night regardless.

Farrell did a rough calculation in his head: If sleep apnea affected just one out of a hundred snorers, it would be a $100 billion business. Farrell and Sullivan raised $600,000 to commercialize Sullivan's machine. The new company, called ResMed, introduced its first continuous positive airway pressure device, known as a CPAP, into the market in 1989. Within five years, the company was making $300 million a year in revenue.

A study in 1994 found that about 10 percent of women, and 25 percent of men, have difficulties breathing in their sleep. These numbers climb as a person gets older, so that as many as one out of three elderly men have at least a mild case of sleep apnea. All told, about 20 million Americans have the disorder.

Its cause could simply be the trade-off that the human body makes for having the ability to speak in a complex language. Homo sapiens differed from Neanderthals by developing a flatter face, a smaller jawbone, and a tongue that descends deeper into the throat than in any other mammal. With this new hardware, humans were able to move beyond making simple grunts. Those first, complicated sounds uttered by Homo sapiens soon developed into language. Jared Diamond, a professor at UCLA, called the positioning of the tongue our greatest evolutionary advantage. "It's easy to appreciate how a tiny change in anatomy resulting in capacity for speech would produce a huge change in behavior," he noted. But the positioning of the tongue in the Homo sapiens mouth complicates the acts of eating, drinking and breathing. Food could literally go down the wrong pipe, a biological problem unique to modern humans. The longer tissues of the soft palate at the back of the throat made it possible for the airway to become blocked after a routine exhalation, which could start the cycle of sleep apnea. A large neck, tongue, or tonsils, or a narrow airway often signal that a person will develop sleep apnea because of the increased chance that breathing will become blocked during the night.

Sleep apnea is a flaw that is part of the blueprint of the human body, and excess fat often teases it out. The chances of developing sleep apnea go up with weight because the tissues in the throat become enlarged, making it more likely that they will obstruct the airway during sleep. For some patients, losing weight alone can solve the problem. Other changes in behavior - like drinking less alcohol, cutting back on smoking, sleeping on one's side instead of on the back, doing exercises or playing musical instruments that build up the muscles in the throat - can also help.

Breathing masks like ResMed's are the most common medical treatment for sleep apnea, but they aren't for everyone. Some patients never get used to the awkward sensation of sleeping with a mask on their face, or never become comfortable with breathing in the cold air that is continuously pumped into their mouth through-out the night. In the long term, patients with mild sleep apnea wear the masks between 40 and 80 percent of the time, according to various studies.

Dental devices are typically the next choice. These aren't as effective as CPAP machines for severe sleep apnea, but they may be easier for some patients to use, especially those who have to travel frequently. One of the most popular looks like a sports mouthguard. It forces the lower jaw forward and slightly down to keep the airway open. Another device holds the tongue in place to prevent it from getting in the way.

I made my way to Peter Farrell's office in the ResMed building. He sat behind his desk, oval glasses perched on his nose, and stared at me with the intensity of a boxer. He had made a fortune from his work with Sullivan. Still, he thought that sleep apnea remained poorly understood and underrecognized in the United States. "We are still in the early phases of a monster area," he told me, in a thick Australian accent. "This is arguably the biggest health problem in the country and we think that three in 10 adults have it. There isn't anything remotely close to that. We have so much runway ahead of us that it's like we haven't even started."

Much of ResMed's growth has come since 2000. That year, four separate studies found conclusive evidence that sleep apnea was associated with increased rates of hypertension. Left untreated, patients with sleep apnea are at a greater risk of developing kidney disease or vision problems, or having a heart attack or stroke. Those studies helped convince government insurance programs such as Medicare, Medicaid, and the British National Health Service to pay for a portion of the cost of each device, which can be several-thousand dollars if a patient were to buy it out of pocket.

As scientists began to understand sleep apnea in more depth, they started to see it as the foundation for serious illnesses affecting the mind. In one study, researchers at UCLA conducted brain scans of patients with long histories of sleep apnea and compared them with the scans of control subjects who had normal sleep patterns. The investigations focused their inquiry on the mammillary bodies, two structures on the underside of the brain so named because they resemble small breasts. Mammillary bodies are thought to be an important part of the memory and have long been associated with cases of amnesia. This memory center of the brain was 20 percent smaller in patients with sleep apnea. Had a doctor looked at a patient's brain scan alone, it would have suggested severe cognitive impairment: a similar shrinkage in the size of the mammillary bodies is found in patients with Alzheimer's disease or those who experienced memory loss as a result of alcoholism. It was the first indication that sleep apnea leaves a permanent scar beyond the daily difficulties of focus and attention that come with sleepiness. "The reduced size of the mammillary bodies suggests that they suffered a harmful event resulting in sizable cell loss," noted Ronald Harper, professor of neurobiology at the David Geffen School of Medicine at UCLA and the lead investigator for the study. "The fact that patients' memory problems continue despite treatment for their sleep disorder implies a long-lasting brain injury."

Sleep apnea's effects on the brain can also have devastating consequences on the highway. By any measure, commercial truckers have a difficult job. Confined to one position and forced to maintain attention for a long time while racing to meet constant deadlines, many truckers wear the signs of stress on their bodies. Stefanos N. Kales, an assistant professor at Harvard Medical School and the Harvard School of Public Health, began tracking the outcome of a truck driver's lifestyle, including poor nutrition, little exercise and less sleep. Obesity was widespread and contributed to a much higher rate of sleep-disorder breathing than what is found in the general population. By Kales's estimates, a driver with sleep apnea was seven times more likely to get in an accident. More disturbingly, Kales found that one out of every five accidents involving a commercial truck was caused by its driver falling asleep at the wheel.

Drivers are rarely willing to admit that they have sleep apnea, much less seek treatment, because doing so could increase their chances of losing their commercial licenses and livelihoods. Kales led a study in which his team observed nearly five hundred truckers from fifty different companies over a period of 15 months. Screening questionnaires flagged about one in every six drivers as showing signs of probable sleep apnea. Of these, only 20 drivers agreed to spend a night in a sleep lab. All were shown to have the disorder. And yet only one driver out of the group began treatment, using a CPAP device regularly. "Screenings of truck drivers will be ineffective unless they are federally mandated or required by employers," Kales and his team members noted.

Author's Bio
David K. Randall is a senior reporter at Reuters and has also written for the New York Times, Forbes and New York. He is an adjunct professor of journalism at New York University and lives in Brooklyn, New York.
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