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Inspiratory Squeak and Palpitations
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Inspiratory Squeak and Palpitations

I'm a 40-yr-old non-smoking woman of healthy weight/lifestyle. I’ve had a wheeze for 1.5 years. It's a short squeak, usually single-tone, sometimes two-toned, and occurs during the mid-to-later part of an inhalation. I’ve never heard it exhaling. My doctor heard it during a routine exam a year ago (she asked me if I’d recently had bronchitis, which I hadn’t), and I also hear it often when I take in a big breath to yawn, cough or inhale. It's always only on the left side. I hear it more frequently lately.

Recently I went back to my doctor because the wheeze had not gone away, and I was also starting to feel difficulty catching my breath when I’m physically active. She sent me for an asthma test, spirometry and chest X-ray, all normal.

I’ve also had heart palpitations/arrhythmia for 2.5 years. A year ago I had a heart ultrasound (normal) and a 48-hour Holter monitor test, which showed 35 separate “runs.” My doctor diagnosed me with an overactive sympathetic nervous system and said I was reacting to stress. At the time, my iron level was low (29). I’ve been on supplements for a year and my iron has come up to 71.

I should feel reassured that the heart tests were normal, but I’m having a hard time believing the palpitations, which have become more frequent in the past year, are an overactive sympathetic response. They often happen suddenly when I am at rest and are not associated with stressful thoughts, sweaty palms or anxiety. They are also aggravated by my body position – lying on my right side, on my back, or bending over can cause my heart to start pounding and beating irregularly. Since I have lung symptoms as well I am unsure whether or not I should talk to my doctor about more testing. I'm reluctant to push the issue since I've already had tests and they've been negative.

What I really would like to know is, can it be normal to have a small squeak when I inhale, and should I just learn to live with it? Could the heart and lung symptoms be related?
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It is noteworthy that your “squeak” occurs with inhalation rather than with exhalation, the latter characteristically seen with asthma and bronchitis.  The presence of inspiratory squeeks or wheezes suggests what is called upper airway obstruction.  This can occur with anatomic abnormalities of the larynx and/or vocal cords (for example, polyps) or functional abnormalities of the vocal cords,  prime examples being vocal cord dysfunction and vocal cord weakness or paralysis.  You should request direct examination of your larynx and cords, by a specialist (ENT or Pulmonologist).  You might also ask your doctor if an inspiratory flow volume loop was performed as part of the pulmonary function testing and, if so, was it abnormal.

Your concern about abnormal heart rhythm(s) (arrhythmias) is warranted, especially with the report of “35 separate runs”.  Many arrhythmias can cause shortness of breath.  The allegedly normal ultrasound exam does not rule out serious abnormal rhythms and may not provide clues as to the cause of the arrhythmias.  After all this time and seeming uncertainty about your heart rhythm and the potential impact of such on your exercise capacity, this would be a good time for you and your doctor to request consultation with a cardiologist, ideally a cardiologist with experience in the electrophysiology of the heart.

Finally, your doctors might want to reconsider the cause of your low serum level.  The most common cause of this is iron deficiency resultant from either inadequate iron intake and/or chronic blood loss (most often gastrointestinal) that depletes the body iron stores.  There is, however, an uncommon but not rare form of anemia called B-Thalassemia or Thalassemia trait that can be associated with low serum iron values.  The most important approach to anemia with low serum levels is to make sure that it is not reflective of chronic blood loss from any part of the body.

You may have to be assertive to proceed with one or more of the above evaluations but, at age 40, you are still a young woman and more intensive medical intervention now may save you a lot of grief in the years to come.

Good luck
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