ResMed Origins
`
`Contents
`
`Foreword
`
`Preface
`
`OSA in antiquity to 20th Century
`
`Sleep research in the 20th Century
`
`Professor Colin Edward Sullivan
`
`Nasal CPAP
`
`Dr Peter Craig Farrell
`
` 2
`
` 3
`
` 5
`
` 6
`
` 9
`
`11
`
`14
`
`Baxter Centre for Medical Research 1986 - 1989 16
`
`ResCare 1989 -1995
`
`Epilogue
`
`Treatments of OSA (other than CPAP)
`
`Comorbidities
`
`Awards ResMed group
`
`Awards Dr Peter C Farrell
`
`ResMed Patents issuing prior to IPO
`
`Timeline of product introductions
`
`ResCare staff 2 June 1995
`
`References
`
`ResCare Organisation Chart
`
`Lancet 18 April 1981, pp 862-5
`
`Endnotes
`
`21
`
`31
`
`33
`
`34
`
`35
`
`37
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`37
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`38
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`40
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`41
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`43
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`44
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`48
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`Photo Galleries 55
`
`1
`
`RMD 1040
`
`

`
`Foreword
`
`As is detailed later in this document, in 1981 Colin Sullivan and his colleagues introduced their invention of
`continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea. In my opinion, the
`only possible rival for a single product that would produce such an upturn in life expectation and quality of
`life for humanity was the introduction of penicillin. Although sleep specialists were aware that obstructive
`sleep apnea was a very serious illness and surprisingly commonplace, it would be more than a decade after the
`introduction of CPAP before the true and stunningly high prevalence would be documented by Terry Young and
`her colleagues. Rarely in the history of medicine has an eff ective treatment for an illness been developed before
`the true magnitude of the problem was scientifi cally established.
`
`The next big challenge after 1981 was to convert the Colin Sullivan vacuum cleaner device into a practical, eff ective,
`and dependable treatment for the literally millions of apnea victims around the world. Referring again to the
`penicillin analogy, victims on the verge of dying from pneumonia or wound infections could be miraculously
`restored to health by the antibiotic if it could be made very widely available. To see individuals who are failing
`in every aspect of their lives including their cardiovascular function and their daytime alertness restored to high
`energy and good health is a joy and a miracle.
`
`The next huge challenge facing sleep professionals as well as victims of obstructive sleep apnea is the lack of
`eff ective public awareness about the problem. It remains an ongoing process to identify all the victims of sleep
`disordered breathing and make them aware that there is an eff ective treatment which will restore their lives and
`health. ResMed is completely committed to enhancing public awareness.
`
`In conclusion, we must congratulate this pioneering company for its many successes, and we strongly encourage
`its continuing eff ort to improve therapeutic approaches and to support vastly expanding public awareness.
`
`William C Dement MD PhD
`Stanford University
`
`2
`
`Foreword
`
`2
`
`

`
`RESMED ORIGINS
`
`3
`
`Preface
`
`ResMed has been conspicuous on the world
`business scene since
`it
`listed on the NASDAQ
`stock exchange
`in June 1995,
`raising US$24
`million. By 2007, market capitalisation exceeded
`US$3 billion.
`Internationally, ResMed markets
`its products in over 80 countries. In each, it is leader
`in both market share and in technical excellence.
`For more than a decade, business assessors in the
`USA have recognised distinguished achievements.
`In Australia, its country of origin, ResMed has received
`accolades for design of its products and it has won
`awards for export sales. Its Founder has won awards
`from the community in Australia, and from his
`peers, in Australia and the USA, for leadership and
`professional expertise.
`
`ResMed’s business is based on devices for diagnosis
`and treatment of sleep disordered breathing (SDB)
`and its most extreme manifestation - obstructive
`sleep apnea (OSA) i*. The characteristic feature of
`OSA is the repeated sequence of increasingly heavy
`snoring, followed by cessation of breathing, with
`gasping arousal, and return to sleep. Consequences
`are insidious, increasing in severity as the disease
`advances. Consequences arise from mechanical
`damage to tissues from snoring and psychological
`disturbances from sleep disruption. Other mechanical
`eff ects are produced by highly variable pressure in
`the thorax that disrupts the heart’s control of blood
`volume to cause nocturia. Pressure variations in the
`thorax also cause refl ux of stomach contents into
`the esophagus. Frequent intermittent starving of the
`organs of oxygen combines with stress to cause a
`range of lethal cardiovascular diseases and metabolic
`disturbances connected to diabetes.
`
`OSA is a disease of global signifi cance. It is highly
`prevalent in every society where it has been studied.
`Symptoms of the disease are so conspicuous that they
`have been the source of comment for at least 2,000
`years, yet it was only in the 1960s that physiologists
`recognised OSA as a distinct disease entity. Following
`recognition of OSA, studies of pathophysiology and
`the extent of its consequences were inhibited by the
`
`absence of an acceptable and successful method of
`treatment. With no available treatment it was diffi cult
`to establish cause and eff ect between symptoms and
`consequences.
`
`When a scientist from the University of Sydney
`announced a treatment, the news was met with
`incredulity by the medical establishment.
` The
`equipment used
`for
`the demonstration was
`improvised and primitive. Theory behind the method
`had either not been considered by others or had
`been rejected without experimental testing. It took
`the genius of a medical scientist who was prepared
`to experiment and test what others had ignored
`or argued against, before success of this unlikely
`treatment was demonstrated.
`
`Invention is only the fi rst stage in the tortuous
`process of innovation. One successful demonstration
`is a long way from a marketable product that can be
`manufactured on an industrial scale. In this example,
`a great deal of R&D was needed to convert an
`improvised apparatus into an industrial product. It
`took determination, persistence, and the proselytising
`enthusiasm of an evangelist to convince fi nanciers
`to invest in a R&D project of unproven utility. The
`requirement then was for engineers, designers, and
`medical researchers to create a technology that
`would be cost-eff ective and patient-acceptable.
`Finally, the medical profession had to be convinced
`and then educated, manufacturing plants built, and
`a global marketing infrastructure established. This
`gargantuan task was taken on the shoulders of one
`academic/engineer/industrialist.
`
`The story told here is an acknowledgement of the
`resounding success of the formation and operation of
`the ResMed group of companies in fi lling every need.
`ResMed stands out conspicuously and favourably
`as a paragon against the bursting dotcom bubble.
`That fi nancial disaster arose from innumerable failed
`attempts by others directed toward a similar goal
`of industrial success from academic origins. The
`continuing commercial success of ResMed over a
`
`* Numbers in parenthesis in the text indicate references, identifi ed in the Appendix. Endnotes are indicated by superscript Roman numerals.
`
`Preface
`
`3
`
`3
`
`

`
`4
`
`RESMED ORIGINS
`
`period of almost two decades has attracted attention
`of scholars of business management from the
`level of the local high school, through government
`bureaucracy, to the hallowed halls of Harvard (54).
`
`The contrary conventional wisdom of established
`and conservative professions combined with their
`innate inertia to create a variety of obstacles to the
`formation and eventual success of ResMed. This
`innovation relied heavily on the two key individuals
`who met and overcame all the challenges of defi ning
`an invention and taking innovation through to the
`global marketplace. Together they led the world
`into a new era of therapy with products that were
`commercially viable, and therapeutically eff ective
`against one of the major infl ictions of humankind.
`Both had backgrounds that uniquely prepared them
`for the roles they had to play. How this came about is
`the main theme of this narrative. The period covered
`is from antiquity to 2 June 1995, when the company
`listed on the NASDAQ stock exchange.
`
`The continuing success of ResMed means that this
`narrative considers only the fi rst episode of a serial story
`that has no end in sight. This episode is concerned
`with the struggle to found a global organization.
`The next episode of growth and consolidation is left
`for others to cover, for the theme and challenges
`changed subsequent to the listing. The success of
`the listing was recognition that ResMed had become
`a mature operation, taking its place alongside other
`western industrial companies.
`
`Such success would not have come without the
`inspired eff orts of a small group of dedicated
`engineers and support staff . Starting as a handful,
`numbers
`increased until the organisation chart
`comfortably fi lled one page, as shown in the Appendix
`for 22 July 1994. In this text it is not practical to detail
`the contribution of each individual. It is a tribute
`to inspired leadership that staff relationships were
`harmonious, with signifi cant achievements being
`made weekly. Over a score of those in Australia who
`brought the Company to listing are still with ResMed
`
`in 2007, when global staff numbers exceed 3000.
`
`Of those who have left, special gratitude must be
`expressed to Chris Lynch. He played a critical role
`in the very early days, and was forced to leave only
`when struck down by multiple sclerosis. Ken Hely
`was instrumental in development of successful early
`masks. He also left for medical reasons. Each made
`greatly appreciated contributions.
`
`On a happier note, ResMed has operated as
`a
`training ground
`for people seeking career
`advancement beyond what could be off ered in-
`house. Congratulations to Dr Chris Roberts. With a
`scientifi c education, he gained marketing experience
`in another technology company before
`joining
`ResMed. No doubt the management experience he
`gained will serve him well in his new role as Chief
`Executive Offi cer of Cochlear - another Australian
`medical device success story.
`
`A debt too is owed to Bill Nicklin, who brought the
`production of product substantially under one roof
`from a scattering of contractors. He too has moved
`to a senior management role in another technology
`start-up company. Wal Flicker worked long and hard
`as Company Secretary and Director and manager
`and operator of anything and everything to do with
`fi nance and spending and organising this and that.
`Shirley Sproats joined and remained until December
`2005 as a most dedicated accountant, bookkeeper,
`personnel manager, and odd job person when the
`term multitasking was invented for ResCare staff
`activities.
`
`The Company would not have succeeded without
`the dedicated eff orts of these and many others.
`
`Sherill Burden, Colin Sullivan, William Dement, and,
`Christian Guilleminault are thanked for photographs.
`Lisa and Lance Hopper and Lucy Bode prepared the
`design and layout for printer, John Mockridge.
`
`Charles S Barnes PhD FTSE 26 May 2007
`
`4
`
`Preface
`
`4
`
`

`
`RESMED ORIGINS
`
`5
`
`OSA in Antiquity
`to the 20th Century
`
`“You can’t cross a chasm in two small leaps”
`
`David Lloyd George, Former British Prime Minister
`
`is so obvious
`The symptom of heavy snoring
`that historians had noted extreme examples in
`documents going back to antiquityii. Notable were
`members of the Ptolemy dynasty that ruled Egypt
`for 300 years until Julius Caesar took control of Egypt
`(and Cleopatra) in 30 BC. Many of the Ptolemys had
`symptoms that are associated with OSA. Family
`members were recorded as being hugely obese,
`with indications of a genetic propensityiii to obesity
`(4). There are many other records of apparent OSA
`symptoms, such as heavy snoring and obesity, in
`prominent historical fi gures. These include Emperor
`Napoleon Bonaparte (5), Queen Victoria, US President
`Taft (6, with BMI >40), both Presidents Roosevelt, and
`Johannes Brahms, composer of a lullaby for infants (7).
`We can only speculate how the disease aff ected their
`reasoning, and what eff ect treatment would have had
`on history.
`
`By the early 1800s, medical professionals were taking
`an interest in the interrelationships between obesity,
`sleep, and breathing. In those days, diagnosis had to
`rely on what the physician could see, hear, and feel.
`In 1816, William Wadd (8), Surgeon Extraordinary
`to King George III, wrote a critical review of current
`knowledge in a monograph: Cursory Remarks on
`Corpulence; or Obesity Considered as a Disease: With a
`Critical Examination of Ancient and Modern Opinions
`Relative to its Causes and Cure. In it he noted that in the
`obese, “respiration is performed imperfectly, or with
`diffi culty”, and that obese people ”could fall asleep at
`any time”.
`
`The most infl uential description in the 1800s was not
`from a physician, but from the novelist Charles Dickens.
`In 1836-7, when he was a young man in his 20s,
`
`Dickens published a novel in serial form with the title
`The Posthumous Papers of the Pickwick Club. This made
`him famous as a novelist. The book can still be read
`on the Internet. In his novel, a conspicuous character
`called Joe was an excessively sleepy, red-faced, loud
`snoring, cognitively dysfunctional, “wonderfully fat”
`boy with peripheral edema. Joe’s symptoms are
`reminiscent of OSA. Mr Pickwick himself was obese,
`and after imbibing too much would drop off to sleep,
`snoring, with choking sounds. Dickens’ impact on
`the medical profession was substantial. Sir William
`Osleriv, a Canadian who became Professor of Medicine
`at Oxford, was one of the most infl uential persons in
`medicine around the late 19th and early 20th centuries.
`Osler adopted the term Pickwickian Syndrome before
`the condition could be adequately diagnosed.
`
`in 1818 and
`Scottish physician John Cheyne
`Irish physician William Stokes in 1854 described
`abnormal periodic breathing with central apneas,
`now associated with their names. The London
`physician, WH Broadbent (9), in 1877, gave the fi rst
`detailed description by a medical professional of the
`clinical symptoms of obstructive sleep apnea. He
`described loud snoring, attributed to resistance in
`the pharynx, silence through two or three respiratory
`periods, during which there were ineff ectual chest
`movements, and fi nally respiration resuming with a
`loud snort. He recognised the repetition of this cycle
`“at regular intervals, and the pause was so long as to
`excite attention, and indeed alarm.”
`
`similar observations,
`Other physicians made
`associating obesity with excessive sleepiness, apneas
`due to glottic closure, and snorting arousals. There
`was still confusion between sleepiness due to apnea
`and other sources, for example narcolepsy, which had
`been identifi ed in 1880. The symptoms of narcolepsy
`include an uncontrollable need for sleep, even
`when night-time sleep was adequate. The cause of
`narcolepsy is still not understood, nor is there a curev.
`
`OSA in Antiquity
`
`5
`
`5
`
`

`
`6
`
`RESMED ORIGINS
`Sleep Research
`in the 20th Century
`
`Napolean
`
`
`Queen Victoria
`
`Brahms
`
`“We are more prone to see what lies behind
`our eyes, than what lies before them”
`
`Thomas Henry Huxley 1825-1895
`
`Introduction of electrical measuring and recording
`devices in the fi rst half of the 20th century provided
`tools for the study of the pathophysiology and
`diagnosis of diseases. No longer were medical
`scientists constrained to short-term look, feel, and
`hear observations. Sleep has always been a puzzle
`to physiologists. Though occupying one third of
`a lifetime there was little understanding of why it
`was necessary, or how restorative functions were
`achieved. Instrumentation gave the opportunity for
`meaningful research to the many scientists trying to
`unravel the enigma of sleep. EEG (electroencephalo
`graphy), introduced in 1928, allowed the diff erence
`between brain waves during sleep and wakefulness
`to be recorded. At the University of Chicago in 1953
`Kleitman and Aserinsky identifi ed REM (rapid eye
`movement) sleep with an EOG (electro-oculogram).
`Kleitman went on in 1957 with a student, William
`Dementvi to fi nd the cyclical pattern of REM with non-
`REM sleep, and the relationship of eye movements to
`body movement and dreaming.
`
` In these days when recordings of thousands of
`events can be preserved on a small card, we need to
`be reminded that whole night studies could not be
`made so easily in the 1950s. Recordings were made
`in those days with ink on paper. Shortages of paper
`rolls, and the need for frequent operator attention,
`meant that recordings were made for short periods
`at intervals during the night. Dement (10) notes that
`such limited observations inhibited the discovery
`of sleep cycling, and possibly explains why his work
`did not attract support from other laboratories until
`1959. By 1975, Hobson & McCarley at Harvard had
`identifi ed specifi c brain areas where neurons and
`their associated transmitters controlled the cycle of
`REM and non-REM sleep.
`
`6
`
`The 20th Century
`
`6
`
`

`
`RESMED ORIGINS
`
`7
`
`One hundred and fi fty years on from the appearance
`of Dickens’ novel, the Pickwickian syndrome provided
`a strong stimulus for scientists to apply their new
`tools to the study of respiration in sleep. In 1956
`the Pickwickian syndrome was identifi ed as alveolar
`hypoventilation of obesity by Burwell and coworkers
`(11). Their conclusions were of limited value, as obese
`subjects were studied while awake. Sleep disorders
`were therefore missed, and somnolence was wrongly
`attributed to hypercapnia. The paper was probably
`more important in reviving interest in the Pickwickian
`syndrome in the research community. It was an
`enduring reincarnation, as since 1956 the Medline
`database has acquired 366 entries on Pickwickian
`topics, with at least four papers appearing in the
`fi rst half of 2007. As sleep specialists acquired the
`equipment for physical measurements on sleeping
`subjects they began to rapidly accumulate data and
`make meaningful interpretations.
`
`In 1965, French workers Gastaut, Tassinari, and Duron
`(12), from INSERM and the National Institute of Health
`and Medical Research, and Jung and Kuhlo (13) in
`Germany each published studies of the Pickwickian
`Syndrome. They recorded respiratory airfl ow, and
`thoracic and abdominal movement to recognise
`both obstructive and central apneas. Their work
`may be considered as the fi rst multifunctional
`polysomnographs showing apneas during sleep. The
`technique remains the “gold standard” for diagnosis.
`
`When medical interest was concentrated on the
`Pickwickian syndrome it was the connection between
`obesity and cardiopulmonary comorbidities that
`attracted attention. In 1967-9, French and Italian
`workers found that obesity was not essential for OSA. At
`the same time, Duron et al (14) noted dysrhythmias in
`non-obese patients. The connection of comorbidities
`to sleep then became more important. That the right
`heart was aff ected was shown in France and Germany
`in the 1960s (for example 15). At that time, research
`on Pickwickian syndrome had been almost entirely
`in Europe and the UK. With growing appreciation of
`the connection between sleep and breathing, the
`fi rst Symposium for sleep and respiratory specialists
`was held in Italy in 1972. Dement records that these
`events were completely ignored in the USA.
`
`Also at that time, a French Professor of Neurology
`in Psychiatry, Christian Guilleminault, was showing
`interest in respiratory disorders during sleep. He had
`been a Post-doctoral Fellow at Stanford in 1970. In
`1972 Guilleminault became an Associate Director
`of the Stanford Sleep Disorders Clinicvii set up by
`William Dement in 1970. Until Guilleminault’s arrival,
`the Stanford Sleep Clinic had not routinely included
`respiratory or cardiac sensors in their night studies.
`Dement acknowledges
`(16)
`that Guilleminault
`“immediately insisted we pay more attention to sleep
`disordered breathing”. By 1978, they demonstrated
`the correctness of the postulate that upper airway
`dilator muscles were keeping the airway open during
`wakefulness and were adversely aff ected when
`breathing occurred during sleep.
`
`Earliest known sleep polysomnogram published by
`
`Gastaut et al in1965
`
`William C Dement
`Professor of Psychiatry &
`Behavioral Sciences
`Stanford University
`
`The 20th Century
`
`7
`
`7
`
`

`
`8
`
`RESMED ORIGINS
`
`Guilleminault, Tilkian, and Dement published the
`fi rst major review on The Sleep Apnea Syndromes in
`1976 (17). They covered the area with 93 references.
`By 1976, the Stanford Sleep Clinic had studied
`350 people referred for sleep diffi culties. Using
`polysomnography, sleep apnea was found in 62. From
`this sample Guilleminault and Dement identifi ed
`apnea symptoms of snoring, a possible relationship
`to SIDS, abnormal body movements during sleep,
`sleepwalking, enuresis, morning headache with some
`disorientation, and excessive daytime sleepiness.
`They noted that there was no necessity for obesity,
`that males accounted for the higher proportion of
`suff erers, and that occurrence of some apneas was
`normal. It would be another 13 years before enough
`data had been collected and verifi ed to justify
`publication in 1989 of the fi rst edition of Principles and
`Practice of Sleep Medicine (18). This was then, and later
`editions have remained, the standard text on sleep
`medicine.
`
`Slowly, scientists whose main interest had been
`restricted to sleep and its eff ects on health, had reason
`to extend their interest to disordered breathing,
`and its eff ects during sleep. Here was a whole new
`area of disease interactions with largely unexplored
`ramifi cations to health. There were strong hints that
`the heart, circulatory system, and lungs could be at
`risk. Research emphasis quickly shifted from Europe
`to universities in North America. Between 1975 and
`1980, 319 articles appeared on sleep and apnea in
`the medical literature. That was fi ve times as many
`as in all previous history. This fi ve-year period marked
`the beginning of an intense era of research that still
`continues with increasing momentum.
`
`Thus far it was known that the airway blockage
`during apnea was somewhere in the upper airway.
`Early workers had assumed the pharyngeal area. At
`the University of Texas in 1978 Remmers and co-
`workers (19) used pharyngeal intubation and pressure
`measurements to demonstrate that the locus of
`
`airway closure lay in the oropharynx, not the larynx.
`
`One of the North American scientists becoming
`involved with sleep-disordered breathing was Eliot
`Phillipson. A Canadian, Phillipson earned his MD
`(1963) and Master of Science in Medicine (1965) from
`the University of Alberta, and gained cardiovascular
`experience at the University of California, San Francisco
`(1968-71). He joined the research and clinical staff at
`the University of Toronto in 1971. There, he established
`a reputation for his studies of respiratory control in
`dogs. This was “pure” or “basic” research, using an
`animal as a model for experiments that would not be
`possible on humans. In 30 years of research between
`1970 and 2000, Eliot Phillipson published 40 papers.
`All were on breathing in dogsviii.
`
`To study respiration, the animal was connected to
`the same recording devices as were used for human
`polysomnography. Respiratory airfl ow was always
`important. It could be measured with a tube 10
`mm in diameter inserted into the trachea through
`a tracheostomyix – a hole cut into the windpipe
`to gain access to respiratory airfl ow. Flow was
`measured with a diff erential pressure transducer and
`a pneumotachograph for the rate of airfl ow to and
`from the lungs. Respiratory airfl ow could then be
`measured in response to experimental challenges,
`such as change in composition of respiratory gases or
`stimulation of the vagal nerve. By 1976, Phillipson had
`gained suffi cient recognition to attract collaborators
`from research scientists in other institutions. One of
`these was an Australian, Dr Colin Edward Sullivan,
`who came as a Post-Doctoral Research Fellow from
`the Department of Medicine, Sydney University.
`
`
`
`Christian Guilleminault
`Professor of Psychiatry &
`Behavioral Sciences
`Stanford University
`
`8
`
`The 20th Century
`
`8
`
`

`
`RESMED ORIGINS
`
`9
`
`Colin Edward Sullivan
`FTSE FAA BSc(med) MB BS PhD FRACP
`
`“One should hold one’s theories by one’s
`fi ngertips so that the least breeze of fact
`might blow them away”
`
`Michael Faraday (1791-1867)
`
`Dr Sullivan completed his basic medical qualifi cations
`of Bachelor of Medicine (MB) and Bachelor of Surgery
`(BS) in 1970, extending his medical qualifi cations
`in 1967 with a Bachelor of Science, Medicine with
`Honours, at the University of Sydney. He was
`awarded a PhD in physiology in 1977. In this period
`he held a research position in thoracic medicine and
`a clinical position as Resident Medical Offi cer at the
`Royal Prince Alfred Hospitalx (RPAH), a major teaching
`hospital affi liated with the University of Sydney.
`
`Like many Australian medical institutions, RPAH has
`always taken strong pride in research and in being
`a leader in applying new clinical procedures. One
`way of fostering such strategies was by exchanges of
`scholars with other leading research centres. Thus it
`was a John Read Memorial Fellowshipxi of the Asthma
`Foundation of New South Wales and a Post Doctoral
`Research Fellowship of the Department of Medicine,
`Sydney University that took Sullivan to Phillipson’s
`laboratory.
`
`Arriving in Toronto, Colin Sullivan had a strong
`background
`in physiology, particularly of
`the
`respiratory system, and in clinical medicine. The
`academic atmosphere at the University imbued him
`with a passion for acquiring knowledge through
`research. In the laboratory at Toronto, Sullivan’s
`work was with eff ects such as hypoxia, hypercapnia,
`control mechanisms during REM and non-REM sleep,
`arousal, and laryngeal stimulation. All this was on the
`respiratory system of dogs.
`
`In 1978, Sullivan received the Cecile Lehman Mayer
`Research Awardxii of the American College of Chest
`Physicians for original research on the infl uence of
`
`Colin E Sullivan
`Professor of Medicine
`University of Sydney
`
`sleep on airway smooth muscle tone. He had joined
`the thin ranks of scientists working on sleep and
`breathing.
`
`In 1979 Sullivan returned as a Senior Lecturer to the
`University of Sydney, where he continued working
`with dogs, and,
`importantly,
`resumed clinical
`treatment of patients.
`
`Sullivan had a long-term interest in the role of the
`upper airway in cot death, often called SIDS, an
`acronym for the descriptive term sudden infant
`death syndrome. Dogs were used as a model for
`measuring and comparing responses to nasal and
`tracheal occlusion. Now, instead of entering the
`airway though a tracheotomy, as was done in Toronto,
`Sullivan devised a method for using the entire normal
`respiratory tract, including the nose. To do this, a
`fi breglass mask was moulded to fi t over the dog’s
`snout. It was glued in place with silicone adhesive,
`which also ensured an airtight seal. Air, or other
`experimental gas, could then be delivered through
`the mask directly into the nose to contact the whole
`airway. Similarly, sensors or other instrumentation
`could be located in the mask to react to respiratory
`airfl ow (22).
`
`In his review, Disorders of Breathing in Sleep, published
`in 1980 (23), Sullivan was able to identify 6 major
`disorders. These were described as OSA, snoring,
`central sleep apnea and hypoventilation, Cheyne-
`Stokes breathing,
`REM-sleep-coupled
`arterial
`haemoglobin oxygen desaturation in chronic lung
`
`Colin Sullivan
`
`9
`
`9
`
`

`
`10
`
`RESMED ORIGINS
`
`University medical courses had little if any content
`on sleep and no teaching on breathing during sleep
`to alert primary care physicians to the dangers of
`snoring. It was clear that much fundamental research
`would be needed before a basic understanding could
`be gained on all these matters. Many years would
`pass before knowledge of sleep-disordered breathing
`fi ltered through to primary care physicians.
`
`disease, and sudden infant death syndrome. Obesity
`was recognised as a predisposing factor. Interestingly,
`Sullivan hypothesised that the reverse could also be
`true, that is, that OSA could contribute to obesity.
`This was based on sleep time in animals. In 1999
`his hypothesis received support when CPAP was
`shown to reduce leptin levels in obese OSA suff erers.
`Subsequently there have been several confi rmatory
`and extending studies of eff ects of OSA and CPAP on
`leptin and other appetite-moderating hormones.
`
`In 1980, Sullivan could point to a spectrum of
`clinical consequences of OSA.
` He
`listed noisy
`snoring, excessive daytime sleepiness, intellectual
`and personality changes (including depression),
`pulmonary hypertension, right heart failure, systemic
`hypertension, nocturnal arrhythmias, abnormal
`nocturnal motor activity (choking and panic attacks),
`morning headache, unexplained polycythemia, and
`sudden unexpected nocturnal death. These are all
`serious conditions needing treatment, or preferably,
`prevention.
`
`By 1980, the medical research community working
`on sleep-disordered breathing was well aware that
`they were in an area of immense potential. However,
`this knowledge was eff ectively confi ned to a relatively
`small group of elite research scientists. Among
`the research community interest and dedication
`had become intense, tinged with a high degree of
`competition to be fi rst with signifi cant fi ndings.
`
`Patients being studied were not representative of the
`community at large, as most had been referred to
`major teaching hospitals or specialist clinics because
`of the severity or unusual character of their conditions.
`Little was known of the cause of any of the disorders
`of breathing during sleep. Apart from these specialist
`research scientists, there was still very little knowledge
`in the community or among primary care physicians
`of the prevalence of these disorders, or the extent
`of their long-term eff ect on morbidity or mortalityxiii.
`
`10
`
`Colin Sullivan
`
`10
`
`

`
`RESMED ORIGINS
`
`11
`
`Nasal CPAP
`
`“We must all obey the great law of change
`It is the most powerful law of nature”
`
`Edmund Burke (1729-97)
`
`In April 1981, Professor Colin Sullivan startled the
`research community with a paper (34) in the April
`addition of the prestigious English medical journal
`Lancetxiv. It carried the title Reversal of obstructive sleep
`apnoea by continuous positive airway pressure applied
`through the nares. The paper described successful
`treatment of fi ve OSA patients by maintaining a
`continuous pressure of air into the patient’s nostrils
`during sleep. On application of pressure each patient
`immediately experienced normal sleep, with loss of
`excessive daytime sleepiness and other symptoms.
`That air pressure was the cause of loss of apneas was
`shown by stopping the airfl ow, whereupon apneas
`resumed at the same rate as before treatment.
`Sullivan assumed that the air pressure had acted as a
`splint to hold open the occluded airway.
`
`At the time, this was not a simple experiment. An
`airtight seal had to be maintained in the nose for periods
`of about 8 hours of sleep, during which movements
`of the head would be frequent. Sullivan’s solution
`was to improvise a nasal mask from equipment easily
`accessible in a hospital workshop, using experience
`gained from his dog experiments. In this fi rst series of
`experiments, airfl ow was generated from a vacuum
`cleaner motor. A fl exible tube took the air to a rigid
`wide-bore plastic tube acting as a manifold, and
`held fi rmly under the nose by a headgear. From the
`manifold, two soft silicone tubes entered the nostrils.
`An airtight seal was achieved by gluing the tubes
`in place with silicone adhesive (Dow Corning 382).
`Expiratory airfl ow passed to a tube with a manually
`controlled constriction, varied to adjust pressure up
`to about 10 cm water, as measured on a manometer.
`Other tubes could be inserted into the manifold to
`sample expiratory gasses for CO2 assay.
`
`Results were brilliant, demonstrating total elimination
`of an intractable, progressive disease that had defi ed
`all previous non-i