Dreamland: Adventures in the Strange Science of Sleep (18 page)

A school superintendent calls Wahlstrom about her research about once a week. When I spoke with her, she was working on a study funded by the Centers for Disease Control and Prevention. In a sign that health professionals are starting to take the issue seriously, the goal of the study will be to determine whether teenage sleep deprivation and early starting times at school amount to a public health issue as serious as smoking and obesity.

And yet, even with the abundance of data from school districts across the nation, a steady number of callers seek out Wahlstrom to question whether changing a school’s starting time is really worth it. Many, she says, are school board members or district superintendents who want the same results but don’t know how to sell the later starting time to skeptical parents. “A lot of the concern out there has to do with tradition with a capital T,” she told me. “We have this Puritan work ethic of early to bed and early to rise. But teenagers can go to bed early and be dog tired, and end up staring at the ceiling until eleven.”

10

Breathe Easy

T
his 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. First, the throat closes randomly throughout the night, choking off the body’s air supply. This puts in motion a cascade of increasingly bad side effects. As if on a seesaw, the lack of air causes the oxygen levels in the blood to plummet and the blood pressure to jump. The lips and the skin start to turn blue. Air may not come into the lungs for up to a minute. 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
ghhack-ghhack-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 thirty-eight thousand 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. This procedure, which consisted of making a hole in the throat to allow a person to breathe without using the nose or mouth, was one of the few approved treatments for sleep apnea at the time. It required a permanent quarter-size opening in the neck, however, and was quite painful.

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. Sullivan found an empty room in the hospital and set up equipment to monitor the patient’s breathing and brain waves, which would tell him what stage of sleep the man was in. 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 rapidly went through several cycles of increasing and decreasing the pressure. He found that with the machine’s controls alone, he could effectively turn the patient’s sleep apnea on and off.

The machine worked. The next question was whether its benefits would last all night. 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. Two told Sullivan that they had lost their jobs because of their sleepiness. One subject, a thirteen-year-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. One man, a truck driver, was like many of the patients Sullivan treated: he fell asleep sitting up while talking with Sullivan, and woke up only when he began thrashing his legs in his sleep. When asked about it, he admitted that he had been doing the same thing for more than twenty years. 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. Together, they watched clips that Sullivan had filmed of his patients before and after turning his machine on. In one clip, a man lay on his back snoring loudly. Suddenly his breathing stopped, a sign that his upper airway had closed. Monitors on the screen showed the patient’s heart rate and blood pressure going haywire. Forty seconds later, the airway cleared and the man took another breath. His heart rate and blood pressure instantly spiked. Sullivan finally turned to Farrell and asked, “Do you think that’s good for him?”

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 despite them.

Farrell did a rough calculation in his head: At Baxter, kidney disease accounted for $2 billion a year in revenues, even though it affected just two people out of a thousand. 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.

On a perfect summer day in San Diego, I pulled up to an eight-story glass building next to a private airstrip. Freshly planted trees tied to plastic stakes lined the walkway to the main entrance. A few years ago, this land was one of the last undeveloped parcels within the city limits. Now, it was the headquarters of ResMed’s global business. In the years since the company was founded in Australia, Sullivan’s CPAP machine had become the standard treatment for sleep apnea. Four of every ten patients with sleep apnea in the United States were using a ResMed device when I visited the company. Orders for six hundred thousand new machines a month were coming in. The company had the top-selling CPAP machines in Europe, and was growing its business lines in China and India.

The growth rate had caught the attention of Wall Street. Just a few weeks before I visited ResMed’s headquarters, Jim Cramer, CNBC’s unhinged stock picker, had singled out the company’s stock as one of his weekly choices. “This company is the only pure play on sleep out there!” he screamed. The stock gained several percentage points that day. The day before I arrived, ResMed announced that its sales had grown to $1.1 billion a year. It was in the midst of a fifteen-year streak in which revenues and profits had risen every quarter. As I walked into the company’s global headquarters, employees were just finishing up a party to celebrate. Balloons and the smell of barbecue filled the lobby.

A collection of ResMed’s breathing masks lined the wall. They came in a variety of shapes and sizes, from one that resembled the face mask of a fighter-jet pilot to a small mask designed to fit a four-year-old. One sleek, pink model built for a woman was so thin that it looked like a garden hose. The assortment of models hinted at the fact that snoring, and sleep apnea, aren’t limited to obese patients as originally thought. 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 twenty 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. A short tour of fossils illustrates this point. If you were to look at a Neanderthal’s mouth, you might think that its descendants would have been the ones to survive over the long run, considering their jawbones were larger and stronger than our own. Plus, with extra room in their mouths, Neanderthals never experienced the pain of impacted wisdom teeth.
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. “With language, it takes only a few seconds to communicate the message, ‘Turn sharp right at the fourth tree and drive the male antelope toward the reddish boulder, where I’ll hide to spear it.’ Without language, two proto humans could not brainstorm together about how to devise a better tool or about what a cave painting might mean. Without language, even one proto human would have had difficulty thinking out for himself or herself how to devise a better tool.”