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The important thingies then it's a discussion as to what we need to-do for the patient so I've included is a as a take on and I will read it out for you buy it included in the handouts you’re getting so here's case to year old woman up for middle-aged guy this is a young age but she's coming to me with and if the one that only nine percent and this patient is really struggling look at the amount to air trapping that she has residual vole is so high and chest x-ray shows a flattened diaphragm the diaphragm has a dome shaped and the muscles are radically arranged when the die from contracts that's how you create that vertical axis to allow air to in during sleep the only muscle that’s working in RAM sleep is the diaphragm so allow these patients then have is difficulty with oxygenation at night in fact taking care of her for so many years you can see that you know Gold Digger Software