Download Using CPAP for the long haul: an interview with Steve

Snooze Newz
A newsletter for people with sleep-disordered breathing (SDB) and their families
ISSUE 13
Using CPAP for the long haul:
an interview with Steve Creighton
Steve Creighton didn’t realise he
had sleep apnea. It was only when
he started using CPAP that he saw
how much of life he’d been missing
out on.
Steve Creighton is a professional
driver who lives in Western Sydney
with his wife Kate and their three
teenage children. Kate is a registered
nurse, so she’s always on the alert
for health issues. When she was
pregnant with their first child in 1994,
she was worried about sudden infant
death syndrome (SIDS) so she and
Steve went to see a respiratory
specialist. After speaking to the
specialist about SIDS, Kate added,
“By the way, Steve’s got sleep
apnea.”
“This was news to me,” Steve says,
recalling that day nearly 17 years
ago. “I didn’t think that there was
a problem, but she said when I
was sleeping I stopped breathing
and she had to give me a nudge.
“I felt, wow I’ve got
energy now. I understood
why I needed treatment.
Life was good again.”
I had no idea. But I went to see a
sleep specialist and they said, ‘yes,
you’ve got sleep apnea, you have
20 episodes an hour.’ I remember
thinking, that’s every three minutes,
which seemed like a lot. They put
me on CPAP to see how it went. So
I got a Sullivan™ IV and the effect
was fairly dramatic. I felt, ‘Wow, I’ve
got energy now’. It was really good. I
understood why I needed treatment.
Life was good again.”
They had no trouble with SIDS, nor
with Steve’s treatment for OSA.
“I’ve never had a problem using
CPAP, ” Steve says. “Ok,” he adds,
“the first time I tried it, it was a bit
confronting but I thought: yes—
there’s a mask but let’s get over that,
yes—there’s air flowing, but I could
put the machine on ramp so it would
start off softly and gradually come
up to the required pressure. One of
my sleep studies a few years ago
showed that I actually have borderline
narcolepsy. I’ve always been able
to go to sleep very easily and now
I know why. So sleeping with the
mask has never been a problem.”
Steve takes his CPAP with him when
he travels, including an overseas trip
in 2005. “No problems,” he says.
When he was diagnosed with
borderline narcolepsy Steve was
prescribed dexamphetamine.
He notices that it adds another
dimension to the treatment of his
sleep apnea. “Before I started CPAP
I’d be tired all the time,” he says. “Once
I started on CPAP I’d be fine, but if I had
a big lunch I’d be falling asleep. Now
that I’m having the dexamphetamine I
can take it after lunch and it takes that
edge off the tiredness. So I needed the
combination—it’s not like one thing will
fix you.” Another part of his treatment
was a rhinoseptoplasty because his
septum was crooked. His nose had
been broken when he was younger,
blocking his left nostril. This meant he
had to work harder to breathe. Fixing
his septum didn’t affect his sleep apnea,
but has let him breathe more easily in
general.
Steve has noticed that a number of
people he has worked with are also on
CPAP, but he’s baffled by the people
who say they can’t stay on it. “Some
> continued on page 2
IN THIS ISSUE 30 Years Ago p5 Both Sides of CPAP Therapy p8 Designing for Better Sleep p9
Road safety laws
and OSA
> continued from page 1
Using CPAP for the long haul: An interview with Steve Creighton
“CPAP is something
that’s going to improve
your quality of life
and it’s not just the
tiredness, it’s the longterm effects that sleep
apnea has.”
people say they have trouble staying
on the treatment. I can understand if
they get claustrophobic, but if it’s just
that it feels uncomfortable then they
should get through that. The first time
you ever wore a hat it might have felt
uncomfortable, but if you don’t wear
a hat and you go out in the sun you
could end up with skin cancer. CPAP
is something that’s going to improve
your quality of life and it’s not just the
tiredness, it’s the long-term effects
associated with sleep apnea—the
stress levels, the impact on the heart
and the rest of the body. I’ve been on
it now for 16–17 years and I’m glad. If I
was just starting on it my health would
have been compromised by now.”
Steve suggests a long-term approach
to thinking about having OSA. “Think
about what sleep apnea can do to you
if you’re not treated,” he says. “You
only get one life so it’s up to you to
say, ‘Ok, if this is what I’ve got I’m
going to look at all the options. Apart
from CPAP what other options are
there? Is there a drug that’s an option
for me? Surgery is invasive but is
there a possibility—removing adenoids
or tonsils, or fixing a broken nose?’
Have a look at your diet and exercise.
Obviously!”
As Steve is a professional driver
his use of CPAP is reportable—it’s
marked on his drivers licence and his
government authorization to drive a
bus. He has to see a specialist every
12 months to check on his compliance
and ensure treatment is working.
Steve takes this responsibility very
seriously. “Even after a couple of
days off CPAP I feel the difference,”
2 Snooze Newz
he explains. “If I’ve got a cold, I get
a blocked nose, and I might pull
the mask off during the night. But I
wouldn’t do that two nights in a row.
I’ll go and get something for the cold
so that when I get to bed I know I’ll
be able to sleep.” He explains that he
wouldn’t drive in those circumstances.
“I’d know I wouldn’t be fit, wouldn’t
have the judgment. Because of being
a professional driver I’ve got to take
ownership of it.”
Recently Steve upgraded from the
Sullivan™ IV that he had been using
since 1994. It was still working
effectively, but Kate had heard about
a new generation of flow generators
[ResMed’s new S9™ CPAP]. As
Steve describes it, “Whereas the old
machine was continuous air pressure
the newer one will start off at a low
pressure, sense your breathing and
then only increase the pressure when
it registers that you’re having an
apnea. It’s not continuous air pressure,
it only gives you the pressure when
you need it.” As a bonus, he’s also
finding that humidification with the
new machine is trouble-free.
Kate is still helping Steve with his
sleep apnea. She now works in a sleep
unit and passes on the latest news
on OSA and CPAP. Steve takes full
advantage of this information. “If you
don’t keep up-to-date or have regular
check-ups you don’t know what’s
happening,” Steve says. “You might
find out that what you’re doing is good
but that something new is a lot better.
That’s part of the treatment—making
sure you keep yourself informed.”
All drivers have a personal responsibility to ensure they are fit to drive.
As road safety laws differ across countries, check with your country’s
road safety authority for respective laws related to driving with OSA.
Australia
Road safety laws in most parts of
Australia require all drivers, whether
they are driving a private car or a
commercial vehicle, to report to
their Driver Licensing Authority any
permanent or long-term illness that
is likely to affect their ability to drive
safely. They may be required to
have their health assessed. Medical
conditions that affect a person’s
driving include sleep disorders,
alcohol dependency, heart diseases
and respiratory disorders.
See www.austroads.com.au for
more information.
Europe
A study of 25 European countries
published in 20081 found that:
“Excessive daytime sleepiness is
mentioned in nine [driving licence
regulations], whereas sleep apnoea
syndrome is mentioned in 10
countries. A patient with untreated
sleep apnoea is always considered
unfit to drive. To recover the driving
capacity, seven countries rely on
a physician’s medical certificate
based on symptom control and
compliance with therapy, whereas in
two countries it is up to the patient
to decide (on their doctor’s advice) to
drive again.”
USA
Regulations about driving when you
have sleep apnea differ from state
to state in the USA. In some states
it is mandatory for doctors to report
a patient’s sleep apnea diagnosis.
The Insurance Institute for Highway
Safety website states that if you have
“a history of crashes or violations,
or reports by physicians, police, or
others, state licensing agencies may
require renewal applicants to undergo
physical or mental examinations or
retake the standard licensing tests.”2
UK
UK law requires drivers to tell the
Driver and Vehicle Licensing Agency
(DVLA) about any conditions such
as sleep apnea that may affect their
ability to drive safely. Your ability to
drive will be assessed. Generally, if
you can prove that your treatment
for your OSA is effective, you will be
allowed to keep your licence.
Beccy Mullins from ResMed UK
recently spoke on TalkSPORT Radio
about driving and sleep apnea.
Go to www.realsleep.co.uk to hear
her interview.
Canada
The Canadian Lung Association
reports that: “Doctors have a duty to
tell the motor vehicle board [of their
province or territory] about patients
who are not safe to drive. If you
have sleep apnea and you refuse
treatment, your doctor is required to
report you. The motor vehicle board
could suspend your license until you
get your sleep apnea treated.”3
References:
1. Alonderis A, Barbé F, Bonsignore M, Calverley P, De
Backer W, Diefenbach K, Donic V, Fanfulla F, Fietze I,
Franklin K, Grote L, Hedner J, Jennum P, Krieger J, Levy P,
McNicholas W, Montserrat J, Parati G, Pascu M, Penzel
T, Riha R, Rodenstein D, Sanna A, Schulz R, Sforza E,
Sliwinski P, Tomori Z, Tonnesen P, Varoneckas G, Zielinski
J, Kostelidou K. Medico-legal implications of sleep apnoea
syndrome: driving license regulations in Europe. Sleep
Med. 2008;9(4):362-75.
2. http://www.iihs.org/laws/olderdrivers.aspx
3. http://www.lung.ca/diseases-maladies/apnea-apnee/
drivers-camionneures/index_e.php
FROM THE EDITOR
Celebrating
CPAP treatment
Steve Creighton
has been using
CPAP (continuous
positive airway
pressure) for
nearly 17 years.
He is a very
experienced and
thoughtful CPAP
user and he has
some advice for
people who have just been diagnosed
with OSA (Obstructive Sleep Apnea):
“Think about the long-term effects, what
sleep apnea can do to you if you’re not
treated. And realise that having OSA
doesn’t just affect you, it affects your
whole family—your partner, your kids,
how you react and interact with them,
your whole quality of life. So, if you try
CPAP and it’s a bit uncomfortable—yes
it might be, but it’s going to be more
uncomfortable if you don’t persist and
see what sorts of benefits you might be
able to get from it. I would say, hang in
there and even if you don’t like it, try it for
at least a fortnight and within that time
you should be able to see the benefits.”
Steve is one of the thousands of
people who have benefitted from CPAP
treatment since it was invented in 1981.
This edition of Snooze Newz celebrates
30 years of CPAP with stories from the
earliest days of its use through to how
the latest CPAP devices are designed.
CPAP users and clinicians from all over
the world have shared their stories with
us and we would like to thank all of them
for their generosity and good advice.
If you’ve got a story to tell, let us know.
Sleep well!
Alison Hansford, Global Editor.
Snooze Newz 3
Nicholas Ward makes hay
while the sun shines
“It made a huge and
rapid difference to
both our lives.”
Nicholas Ward is a company director in the UK. For many years
before he was diagnosed, he suffered with what he now knows is
obstructive sleep apnea (OSA).
This year, 2011, marks 30 years since the invention of continuous positive airway pressure
(CPAP). Since then, CPAP devices have delivered a revolution in the treatment of sleep apnea.
Research has kept pace and uncovered a raft of conditions associated with sleep apnea.
Our understanding of sleep apnea, and how to treat it, has come a long way in 30 years.
It’s harvest time in England and
Nicholas Ward and his wife are helping
to make hay by hand while the hay
baler lies quiet and motionless, in
need of repair. He’s just turned 70 and
she’s … younger. Twenty years ago, if
you’d told Nicholas and his wife that he
would be baling hay in his 70th year,
a successful, happy and healthy man,
they would not have believed you.
The fat boy, Joe, in The Pickwick
Papers is Charles Dickens’ most
popular creation among sleep
researchers. He falls asleep at every
opportunity. In this extract, Joe even
sleeps through a battle that is being
re-enacted for the entertainment of
the local gentry.
In the late 1980s, he wasn’t sleeping
properly and his wife was living a
nightmare. She’d lie awake in bed
at night listening to him struggling
for breath, then the silence as his
breathing stopped, followed by
explosive gulps as he started breathing
again. It was a familiar and worrying
cycle. At times, still asleep, Nicholas
would jump up to lean out the
bedroom window gasping for air.
IF YOU’RE A CPAP
USER IN THE UK, VISIT
www.realsleep.co.uk
TO SEE HOW THE
RESMED UK TEAM
CAN HELP YOU WITH
YOUR TREATMENT.
4 Snooze Newz
It was 30 years ago …
In the early 1990s, she arranged
for him to see a sleep consultant in
a London hospital. The diagnosis?
“You’re sleeping too much on your
back”! The consultant’s first step was
to recommend a tennis ball sewn into
his pyjamas, but this had no effect.
“I was an irritable person,” admits
Nicholas. “It affected my work, my
relationships with my colleagues,
friends and family. I put on weight and
it seemed to get worse.” Prompted
by a newspaper article in 1994, his
wife organised an appointment with
leading sleep specialist Professor John
Stradling. By then, Nicholas says, “she
was absolutely desperate”.
Nicholas still has the charts showing
800 arousals on the night of the sleep
study. He was given an “enormous and
heavy crate” to trial, an early Sullivan
CPAP machine. “It was noisy and
leaked like mad,” he says, “but it made
a huge and rapid difference to both
our lives.”
He remembers ramp being a
‘revolutionary’ new feature of the
S6™ he used in 2000. The S7™ was a
much quieter machine, he recalls, but
his mask still leaked and rainout was
always an issue.
Nicholas has recently upgraded to an
S9 Autoset™ and Mirage™ SoftGel
mask and states that there is “no
comparison at all” with previous
models. “They’re so improved, so
different,” he exclaims, “I get a much
better night’s sleep.” His wife’s life has
also improved. “My wife finds it super,
she’s very pleased with it. She can’t
believe how quiet it is,” he says. “She
does notice the odd leak now,” he
confesses, “because they’re
so unusual.”
As a company chairman he travels
frequently. The bulk and weight of early
CPAP machines made flying difficult
and everyone would ask what he was
carrying. “No one worries about my
CPAP now. It’s so small and so many
people carry laptops on planes.”
Nicholas was once ashamed of talking
about his sleep apnea. Now he speaks
of it freely and shows his S9 to friends.
He’s even recommended CPAP to a
few people.
So at the age of 70, fit and healthy
Nicholas and his slightly younger
wife enjoy ResMed’s evolutionary,
intuitive and whisper quiet S9 Autoset
each night. Their happiness would be
complete if the hay baler wasn’t as
quiet as the S9!
Then there was such a ramming
down of the contents of enormous
guns on the battery, with instruments
like magnified mops; such a
preparation before they were let off,
and such an awful noise when they
did go, that the air resounded with
the screams of ladies … Everybody
was excited, except the fat boy, and
he slept as soundly as if the roaring
of cannon were his ordinary lullaby.
‘Joe, Joe!’ said the stout gentleman,
when the citadel was taken, and the
besiegers and besieged sat down for
dinner. ‘Damn that boy, he’s gone to
sleep again. Be good enough to pinch
him, sir—in the leg, if you please;
nothing else wakes him—thank you.
Undo the hamper, Joe.’ The fat boy,
who had been effectually roused by
the compression of a portion of his
leg between the finger and thumb
of Mr Winkle, rolled off the box once
again, and proceeded to unpack the
hamper. [pages 101-102]
In Joe, Dickens described the
symptoms of a person with possible
obstructive sleep apnea (OSA)
decades before scientists did. The
Pickwick Papers was written in
1836–1837. A detailed scientific
description of OSA came 40 years
later from a London physician, WH
Broadbent, in 1877.
Snoring and other disturbances during
sleep have been with us forever, and
they have been noted since ancient
times. The Ptolemy dynasty in Egypt
is said to have had a genetic tendency
to obesity and sleep disorders. It
has been suggested that Napoleon
Bonaparte, Queen Victoria and both
Theodore and Franklin D Roosevelt,
U.S.A presidents, had OSA. But it was
not until the 1950s that the cycles
and body movements of sleep could
even be recorded, and 1981 before
continuous positive airway pressure
(CPAP) treatment was developed.
Sleep apneas and sleep clinics
In 1965 the first polysomnograph
recorded apneas during sleep. In 1970
the first sleep clinic was established
at Stanford University, California,
U.S.A, by William Dement. In 1972
Christian Guilleminault joined the
clinic, concentrating on respiratory
disorders during sleep.
The following five-year period,
1975–80, was an intense time of
research into sleep and apneas with
319 articles appearing in the medical
literature. In 1978 medical researchers
located the source of the obstruction
during OSA, proving that the airway
was closing at the oropharynx,
not further down in the larynx as
previously believed.1
Dogs with masks
In Toronto, Canada, Eliot Phillipson
had started investigating respiratory
control in dogs in 1970. He was joined
in 1976 by Colin Sullivan on a postdoctoral research fellowship from
the University of Sydney, Australia. In
1979 Sullivan returned to Sydney and
devised a mask that would fit over a
dog’s snout to deliver air or a gas.
> continued on page 6
Snooze Newz 5
My wonderful career:
an interview with Bron Lehrhaft
Before CPAP (continuous positive airway pressure) therapy, people with severe sleep disorders would
be given a tracheotomy. Clearly, a less invasive treatment was needed. Bron Lehrhaft was there at the
beginning, treating people with the revolutionary CPAP therapy in Dr Colin Sullivan’s first sleep unit.
> continued from page 5
It was 30 years ago ...
ELECTRICITY
REBATE
Did you know that
some states and
territories provide
a rebate on your
electricity if you use
a CPAP or ventilation
device? These devices
are classed as life
support machinery.
For example, the NSW
Government, Life
Support Electricity
Rebate offers 16
cents per day for
PAP (positive airway
pressure) devices.
You may also be
prioritised for
your service to be
reinstated after a
power failure. Contact
your local electricity
supplier to determine
your eligibility.
6 Snooze Newz
Soon, he was able to extend his
experiments to humans, creating
masks from a plaster cast of each
patient’s nose.
In 1981 Colin Sullivan used his
observations of five patients to write
a paper that would revolutionize the
treatment of OSA.2 He describes
how his patients’ long histories of
noisy snoring and excessive daytime
sleepiness had seriously affected
their lives. Two had lost their jobs
as a result of falling asleep during
worktime, and one boy of 13, was
unable to stay awake at school and
so had been categorised as ‘mentally
retarded’. Sullivan conducted three
all-night sleep studies on each patient,
using CPAP on the third night. He
showed that obstructive sleep apneas
could be reversed by using CPAP to
keep the airway open.
This short paper opened up a whole
new world of treatment. Prior to
this, people with severe OSA had to
have a tracheotomy, which involved
surgery to create an opening in their
throat. Now, they had a treatment
that required no surgery and no
disruption to their life. They could
breathe through the night and
wake-up rested.
was no longer just about relieving
daytime sleepiness—there was the
probability that it had a larger benefit
to health as well. In 2001, further
research showed an increased risk of
coronary heart disease, heart failure,
and stroke when a person’s apneahypopnea index is equal to or greater
than 5 per hour.3
Two had lost their jobs
as a result of falling
asleep during worktime,
and one, a boy of 13,
was unable to stay
awake at school and so
had been categorised as
‘mentally retarded’.
From the earliest CPAP devices,
hand-built from pumps and pool
tubing, we now have a wide choice
of user-friendly, streamlined devices
treating a range of conditions. Colin
Sullivan’s revolution is still unfolding,
as the effects of sleep apnea are
more commonly recognised and
effectively treated. For a piece of
medical research, that’s a lot to
happen in 30 years.
The CPAP revolution
Medical researchers and scientists
started to see the possibilities of this
new form of treatment. Over the next
20 years, study after study built up
evidence on OSA throughout
the world.
In 2000, four separate articles
were published that demonstrated
associations between OSA and
hypertension. This was a turning point
in sleep apnea studies. Treating OSA
References:
1. Remmers JE, De Groot WJ, Sauerland EK, Anch AM.
Pathogenesis of upper airway occlusion during sleep. J
Appl Physiol 1978;44(6):931–8.
2. Sullivan CE, Berthon-Jones M, Issa FG, Eves L. Reversal
of Obstructive Sleep Apnoea by Continuous Positive
Airway Pressure Applied through the Nares. Lancet
1981;1(8225):862-5.
3. Shahar E, Whitney CW, Redline S, Lee ET, Newman
AB, Javier Nieto F, O’Connor GT, Boland LL, Schwartz JE,
Samet JM. Sleep-disordered breathing and cardiovascular
disease: cross-sectional results of the Sleep Heart Health
Study. Am J Respir Crit Care Med. 2001;163(1):19-25.
A tracheotomy is a surgical procedure
that opens up the windpipe (trachea). It
allows people to keep breathing even
when their upper airway is obstructed.
It’s a relatively simple procedure but it
can affect your speech, you can’t swim,
can’t have a bath, and there is a risk
of infection. It is still performed when
necessary, but prior to CPAP therapy it
was the only treatment for people with
severe obstructive sleep apnea (OSA).
research into the conditions associated
with sleep apnea, and a training ground
for sleep technologists. Bron and her
co-workers used their experience
to help improve the treatment, and
worked with the researchers to
understand patterns in the patients’
responses. “It was a really exciting
time,” Bron says. “Nurses do not
usually get to work at the cutting edge
of a whole new area of medicine.”
The unit conducted sleep studies on
two people a night. The studies were
tracked by large monitors, where each
of the 16 channels was nearly the size
of a current PSG. Bron describes these
monitors and rolls her eyes. “They were
very complicated, and I don’t have a
wonderful relationship with complicated
machinery, so that was a steep learning
curve, but I became very adept at it.
You didn’t have anything else.”
When an alternative treatment was
developed, using a mask to deliver
positive airway pressure to keep the
upper airway open, tracheotomies were
no longer needed to treat OSA.
Custom-built treatment
After three or four days in the unit, the
patients would go home taking the
CPAP device with them. They would
have their own mask by then, made
from the plaster cast.
The first sleep unit
Dr Sullivan’s first sleep unit using
the new positive airway pressure
technique opened in 1981 and Bron
Lehrhaft joined the unit three years
later. Bron had completed her nursing
training in 1967 and followed up with a
cardiothoracic diploma at Royal Prince
Alfred Hospital (RPAH), Sydney, in 1968.
She worked in Germany and England
for many years, returning to Sydney in
1984. Obtaining the job at the sleep
unit set her onto a lifetime career. “I’ve
had some really interesting work as a
nurse, and I’ve always loved what I did
and given 100 percent,” she recalls.
“But with this job I just found my
niche. It was just the most incredible
experience working with Dr Sullivan
and his little unit.”
During the first year of the sleep unit
in 1981–82, there were six patients on
CPAP therapy. In 1982–83 there were
a further 14, then in 1983–84 another
40 patients. So there were about 60
patients on CPAP therapy when Bron
started. By the end of the next year,
1985 into 1986, there were more than
90 patients. The unit became a place for
People were sent to the unit from
all over Australia, even though the
treatment was still being fine-tuned.
“At that stage it was very custombuilt!” Bron explains. “Masks were
made by just one person—Jim Bruderer
in the University of Sydney Biomedical
Engineering Department. He would
take a plaster cast of the person’s
nose and make a mask from that. The
masks were glued on to the face with
a Silastic™ type compound that had
to be mixed. But on the first night of
the study with a CPAP device, I would
have to search through a box of spares
and find a mask that fitted as close as
possible and glue it onto the person’s
face. And it might mean that five or six
times during the night I’d have to reglue
it because we wouldn’t want to waste
that time, or money, in having the
patient not using the CPAP device.”
Bron describes the very earliest
machines as using a paint compressor
motor, with the motors reversed.
Thick, white pool tubing attached the
motor to double-ribbed, throwaway,
respirator tubing that fitted to the mask.
This machine could deliver anywhere
between 4 to 20 cm H2O. But, as Bron
says, “It was noisy as anything, had
tremendous turbulence, and breathing
against it was quite difficult.”
Improvements in the system
Initially, patients arranged to come back
to the unit after three or four months,
but Bron felt that more immediate
follow-up was needed. She initiated a
problem clinic in early 1986 and found
that patients who came to the clinic
were doing better, because they were
being seen more regularly. She advised
“CPAP had made an
enormous difference in
their lives. Absolutely
amazing differences.”
patients to call two weeks after they
had their sleep study and make an
appointment to see her. “I discovered
that if you left them longer than two
weeks without any follow-up support
then you had a greater chance of losing
them,” she explains. “If you couldn’t
deal with those problems in the first
few weeks most of the patients would
just give up and say—it’s too hard.”
> continued on page 8
Snooze Newz 7
Designing for better sleep:
an interview with Mark Bertinetti
> continued from page 7
My wonderful career: an interview with Bron Lehrhaft
Both sides of
CPAP therapy
Bron knows CPAP therapy from both
sides now. She started using it herself a
few years ago and it has given her some
unique insights into the treatment.
“We see people at our clinic who are
not using their CPAP device properly so
they think it doesn’t work and it’s not
improving their condition. They might
have a Ramp feature they can use to
increase the pressure until they drop
off to sleep, but they don’t know that.
If the pressure starts off too high you’ll
struggle against it, and every time you
swallow you take in a gulp of air, which
inflates your stomach, making you very
uncomfortable by the morning. So you
won’t keep the machine on all night. The
Ramp feature lets you fall asleep before
the pressure starts moving up.”
“I still think that ResMed masks are, if
not the best in the world, then they’re
among the best in the world. You have
to wear them firmly on your face, but
if you do that they seem to suit the
greatest number of faces. I’m not paid
to say this—it’s what I’ve experienced.
I’ve tried every mask myself for at least
a week.”
“ResMed’s latest, the S9™, fulfils just
about every promise it makes. I use one
myself and it’s an outstanding device,
a totally new concept. The Climate
Control on the tubing, the pressure
delivery, all the other features. This
winter was the first time since starting
CPAP therapy that I haven’t had to put
the sheet over my face to keep the
tubing and mask warm.”
8 Snooze Newz
… and the patients
Her system was successful. In
1986–88 she did a two-year study of
the patients who had been through
the sleep unit and found that 89%
were still using CPAP therapy. “There
were some people who’d fallen by the
wayside and never returned, or who
lived too far away and didn’t come
back, but the ones that came back
were still using CPAP” she says.
“And it had made an enormous
difference in their lives. Absolutely
amazing differences.”
“I still get excited
conducting a sleep
study, watching the
REM marching across
the page then watching
the obstructions and
knowing that I’m
holding in my hands
something that will
make them better.”
The improvements that she observed
included: less depression and more
motivation; blood gas improvements;
stabilization of pulmonary artery
pressure; sleeping through the night;
and reduction in skin problems. One of
her observations about the diabetics in
her care led to a study into the effect of
CPAP on diabetes. The outcome of that
study, Bron tells us, was that “CPAP
will actually improve type 2 diabetes
and improve the glucose levels in the
blood, and obviously insulin levels as
well.”
Bron Lehrhaft is still working in
the field of sleep, and is a Nurse
Consultant, Senior Technologist in a
private clinic. Her face lights up as
she describes her work. “I still get
excited conducting a sleep study,
watching the REM marching across the
page then watching the obstructions
and knowing that I’m holding in my
hands something that will make them
better. I’m the longest serving sleep
technologist in Australia—I don’t know
if it’s in the world, but certainly in
Australia. Since 1984 to now. And it has
been just wonderful.”
Each CPAP therapy device that ResMed makes is a completely new design,
from the motor to the latches. What goes into making a new device?
The first flow generators were big
noisy boxes with pool tubing attached
to handmade masks that were glued
on to each person’s face every night.
They blew air at a constant pressure all
night, you needed a bank of monitors,
and adjustments required an intimate
understanding of the workings of
a complex set of machines. Thirty
years of design work have reduced
these machines to tiny sleek devices
that are almost silent and can deliver
comfortable, individual treatment. They
can tell you how many hours you were
being treated, provide humidification
without condensation, and attach to a
range of well-fitting masks.
Each new CPAP therapy device
has been designed by a team of
engineers, often dedicated to solving
a particular problem. For ResMed’s
S7™, the challenge was to integrate
humidification; for the S8™ it was to
reduce the size of the machine and
make it more portable. The aim for
the S9™ was to make it easier to use,
improve humidification and remove
rainout in the tube, and to be less
obtrusive in the bedroom.
Translating the feedback
Mark Bertinetti is the current Senior
Industrial Designer for Sleep Product
Development at ResMed. He has
worked at ResMed for almost 10 years
on a range of CPAP therapy devices
and accessories. He describes his job
as being a ‘translator’.
“I work with the marketing team
to gather information from CPAP
users, sleep technicians, physicians,
distributors and ResMed staff all
around the world,” Mark tells us. “It’s
great to speak with patients directly.
They tell me what would improve
the treatment for them, and what
feedback they would like. I hear about
their basic daily routine—whether
they wash their masks every day,
whether they pull off the tube, how
they store things, what settings they
use. Then I feed this information back
to the electrical, software, mechanical
and system engineers. I have studied
design, marketing, human factors,
ergonomics, web design, materials and
a range of manufacturing processes so
I understand a little bit of everything.
This lets me translate what I hear from
the users into useful information for the
engineers, and vice versa.”
“It’s very fulfilling
to know that your
work is making
a difference to
people’s lives.”
Mark studied industrial design at
the University of New South Wales,
Sydney, and worked for a design
company for a number of years before
moving to ResMed. He says that two
main things attracted him to this job. “I
really wanted to be part of a company
where you get to interact with all
the major aspects of the design,” he
explains. “The other thing about this
job is that it’s very fulfilling to know
that your work is making a difference to
people’s lives.”
Satisfying everyone
For Mark, a CPAP therapy device
has to satisfy a wide range of needs.
He wants it to be a positive user
experience for all the different people
that touch it during its lifecycle. This
includes the people assembling it on
the assembly line, the physician or
sleep technician using it to titrate in a
sleep lab, the dealer setting it up for a
patient, and finally the patient and their
partner’s experience with it in their
bedroom.
As well as being easy to use,
aesthetically pleasing and able to be
> continued on page 10
Snooze Newz 9
Staying alive
> continued from page 9
Designing for better sleep: an interview with Mark Bertinetti
“As technology
changes we’re
constantly able to
innovate and fix
problems that we
couldn’t fix before.”
produced cost-effectively, each new
CPAP therapy device has to meet
stringent electrical, software, and
mechanical requirements. Mark then
has to consider how it is manufactured,
shipped, packaged, distributed and
stored around the world. It has to meet
business needs, including environmental
responsibilities. Mark describes the level
of detail he went into with the latest
model, the S9, to minimise its impact
wherever possible. He thought about
every aspect, from the number of pallets
that are needed to carry it around the
world, to the number of wires going into
the motor.
“We optimised the size of the S9 to
fit more onto each pallet in a shipping
container, so we can ship 75% more
units in a 40 foot container than with an
S8. Now we’re not shipping air around
the world—we’re just shipping what we
need to ship. We use the bag to hold
everything in place during shipping, so
that minimises packaging.” Mark and
his team have thought about the whole
lifecycle of the product. “Because
the blower is so much quieter we can
use less foam than we used to. All of
the materials that are used are ROHS
(Removal of hazardous substances)
compliant. This ensures that our
materials don’t have harmful substances
like lead, so when you dispose of it
and it breaks down it doesn’t release
hazardous substances. The software and
electronics—everything is minimised.
There’s less wiring—for example, we
used to have seven or eight wires
going into the motor but now we only
have three because the sensing is
done externally.”
Changes and challenges
Some changes are made because people
ask for them, but others only become
possible when the technology develops.
10 Snooze Newz
Mark and his team are always looking
into new technologies and this has led
to significant improvements in CPAP
design and comfort. “For example,” Mark
says, “the new ClimateLine™ heated
air tube delivers optimal temperature
and humidification all the way to the
mask while virtually eliminating rainout.
This was only possible thanks to some
incredible engineering and a new process
that enables us to wind wires into the
tubing’s helix and capture tiny sensors
in the cuff. Prior to these technologies it
wasn’t possible to cost-effectively make
an automatically controlled heated tube.
As technology changes we’re constantly
able to innovate and fix problems that we
couldn’t fix before.”
Change has also occurred in the group of
people who are treated by CPAP therapy
devices. The wide range of devices can
now treat many more conditions, from
basic OSA through to Cheyne-Stokes
Respiration and respiratory failure.
Added to this is a broad population of
well-informed people seeking out CPAP
treatment. “There’s been a definite shift
towards treating much younger users.
Medical practitioners and the public
have become more aware of the effects
of sleep-disordered breathing. Youth
obesity is increasing, lifestyle stresses
are increasing and diagnosis methods are
improving. The older, larger users haven’t
gone away, but a lot more younger,
socially active, working people are using
CPAP. It’s been recognised that women
have different symptoms of OSA, so
there’s a higher proportion of females
than ever before. As we treat people with
different needs, the design will evolve
to accommodate a greater range of
lifestyles, medical conditions, aspirations,
gender differences and social pressures.”
This is a challenge that Mark Bertinetti
welcomes.
Jody Chaitovitz is a retired judge, living in Columbia, Maryland
(USA) with her husband Marty and their cat, Moee. It was a pleasure
to interview Jody – a woman who is passionate, energetic and
enthusiastic while coping with a very painful disability.
Jody has been married to Marty for two
years now, but she insists that “without
my ResMed VPAP™ [variable positive
airway pressure device], the wedding
would never have happened.” Her
central sleep apnea was so bad that
she could not stay awake during the
day. “I was afraid to drive because I
would fall asleep at the wheel, and any
time we went to the movies, I would
sleep through the film. The night that
Dr. Schwartz and Chris Kane tested me
on the VPAP, I slept through the night
like a baby. When I woke up, I felt as
if the world had been washed clean.
I called Marty and told him that I was
coming over to pick him up. ‘Yeah,
right,’ he said. And when I showed up,
was he ever surprised! Things went
from good to better, and we married on
December 27, 2009!”
“Without my ResMed
VPAP the wedding
would never have
happened.” “When I woke up, I
felt as if the world had
been washed clean.”
Her physician, Dr. Alan Schwartz,
Director of the Sleep Center at Johns
Hopkins, diagnosed her central sleep
apnea (CSA) and Jody worked with
him to treat it. “CSA is a form of sleep
apnea where”, as she cleverly puts it,
“my brain sometimes forgets to tell
my lungs to breathe.” She became the
first patient within the Johns Hopkins
system of hospitals in Baltimore
(USA) on Adaptive Servo Ventilation
(ASV) therapy, using a VPAP device.
ASV therapy continuously monitors and
analyzes a person’s breathing pattern,
then provides the variable positive
airway pressure support that they
need. It was created specifically for the
treatment of CSA in all its forms.
Jody had some challenges adjusting
to therapy and getting a proper seal on
her mask, but worked with ResMed’s
Chris Kane to resolve the issues. She
hasn’t looked back since. Now, Jody
says she “owes her life back to her ASV
and ResMed”. Since starting therapy,
Jody has noticed a drastic improvement
in her quality of life and has even
lost 120 pounds (54 kilograms). She
says it’s not unusual for her to sleep
9–10 hours each night, “with dreams in
living color” as she puts it.
Jody’s perseverance was helped by her
very good understanding of medical
conditions. As an Administrative
Law Judge for the US Dept of Labor,
rising to Deputy Chief Administrative
Law Judge for the New England area,
she heard Black Lung, Long Shore,
Whistleblower and Mine Safety cases,
among others. Her career was cut short
only when she became disabled by
the autoimmune disease, Polyarteritis
Nodosa. She describes this as “a
disease which attacks the arteries
by shutting them down. Whichever
organ system or nerves were served
by these arteries, including my lungs,
were often disabled.” It also affected
the nerves of her legs, which made
walking both difficult and painful.
She tells how her rheumatologist,
Dr. David Hellmann, Chairman of the
Department of Medicine at Hopkins
Bayview, told her of his old mentor,
“who described Polyarteritis Nodosa as
‘a hurtin’ disease’, a description more
apt than I would care to take someone’s
word for!”
Jody is still using her original VPAP
machine.* “On the few occasions I fall
asleep without it, I wake up with severe
headaches and nausea, and have terrible
nightmares,” she says. “I still love it as
much as ever, and to tell you the truth,
I don’t know if I’d still be alive today if I
didn’t have it.” It’s not just the VPAP that keeps Jody
alive—her cat Moee has played a vital
role as well. She describes Moee—a
seven and a half year old, almost 20
pound (over nine kilograms) Maine Coon
cat—as her ‘assistance’, or ‘service’,
cat. Jody had been worried about what
could happen if she fell asleep when
she wasn’t using her VPAP and the
CSA caused a failure to breathe that
lasted too long. “But on two occasions,”
Jody tells us, “when I fell asleep at the
computer, I felt a tap, tap, tap on my leg,
both times waking me up fairly quickly.
Another two times, having fallen asleep
reading, he jumped up on the table, and
head-butted me awake! This is not just
‘cute’. This was brought home to me
when I saw an obituary of a 37-year old
man who died of sleep apnea, leaving
his wife and four children. Dr. Schwartz
shows that obituary to his patients as
it’s not about someone ‘rich and famous’
but an ordinary man who was everything
to his wife and children. He told me,
‘Now maybe they will listen!’”
* Jody is currently using ResMed’s VPAP Adapt SVTM,
available in the USA and Japan, and will be soon
moving to an S9 VPAPTM Adapt.
Snooze Newz 11
ResMed products receive
award accolades
ResMed staff members walked away happy from
the 2011 Australian International Design Awards. In
the Medical and Scientific category, the S9™ Series
of flow generators and the Mirage™ FX nasal mask
both won a Design Award, with the S9 Series named
“Best in Category”. The Quattro FX™ Full Face Mask
also starred, being commended for “Good Design”.
The Design Award recognises superior innovation,
while the Good Design category signifies good levels
of form, function, quality, safety and sustainability.
ResMed’s Worldwide Offices:
Global Offices
The right kind of support can
make all the difference to CPAP
treatment. Whether you are
new to treatment or have been
a user for many years, there are
times when you need expert
advice and encouragement.
Join ResMed’s free
sleepVantage or Realsleep*
programs to get the most
benefit from your treatment at
all times, with a free customer
support telephone line to
answer your questions about
CPAP. As a sleepVantage or
Realsleep member you won’t
ever have to feel alone with
your treatment.
Go to
www.sleepvantage.com.au
or www.realsleep.co.uk and
join today, or contact your local
ResMed office.
* Currently sleepVantage is only available
in Australia and Realsleep in the UK.
12 Snooze Newz
United States
ResMed Corp.
San Diego CA USA
Tel: +1 858 836 5000
or 1800 424 0737
Fax: +1 858 836 5001
[email protected]
Australia
ResMed Ltd
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Tel: +61 2 8884 1000
or 1800 658 189
Fax: +61 2 8883 3114
[email protected]
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