Newswise — An online breathing and wellbeing programme helps improve quality of life and breathlessness for people recovering from COVID-19, according to a new study.

This is one of the first clinical trials to report an effective intervention for people with post-COVID syndrome, also known as long COVID. The study is published in The Lancet Respiratory Medicine.

The ‘ENO Breathe’ programme has been developed by the English National Opera (ENO) and respiratory clinicians at Imperial College Healthcare NHS Trust. It uses singing techniques to improve wellbeing for patients with persistent breathlessness due to COVID-19. The social prescribing programme has been providing support to people in London and across England since September 2020 and is led by ENO Engage, the ENO’s learning and participation department.

Patients are referred to ENO Breathe via specialist NHS post-COVID assessment services following a review of their condition and medical treatments. 70 services are now referring to ENO Breathe across London and England. This includes areas that Arts Council England and the Department for Culture, Media and Sport have identified as Levelling up for Culture places such as Blackpool, Peterborough, North Somerset, and Stoke on Trent. The six-week programme is delivered online, starting with a one-to-one session, once-weekly group sessions, and a range of online resources throughout the programme. To date, over 1,000 participants have accessed the free programme.

A clinical trial of 150 participants, with ongoing breathlessness for an average of 320 days since the onset of COVID-19 symptoms, has been conducted by researchers at Imperial College London alongside the programme team at Imperial College Healthcare. The study found that ENO Breathe participants experienced a 10.48 point (out of 100) reduction in breathlessness while running, compared to people who just continued with usual care alone. They also experienced a 2.42 point improvement in the mental component of quality of life, as measured by a validated online questionnaire.

These health improvements were explained in more detail using focus groups and questionnaires, which showed that ENO Breathe participants reported experiencing improvements in their symptoms, felt the programme complemented other care they were receiving, and that using singing techniques and music suited their needs. Additional analyses focusing on participants that went to all the sessions, found improvements in a wider range of respiratory symptoms, anxiety, and had larger quality of life improvements. For example, 40 per cent of ENO Breathe participants experienced a five-point improvement in the mental component of quality of life, compared with 17 per cent in the usual care group. This suggests the participants who engaged most with the programme got the biggest benefit. Though the physical component of quality of life did not improve more in either group.

ENO Breathe uses weekly group online sessions and digital resources, developed with the support of healthcare professionals, to empower participants with tools and techniques to improve the way they breathe and how they engage with their breathing. The programme is led by professional singers from the ENO and focuses on breathing retraining through singing techniques, using lullabies as its musical starting point. No experience or interest in singing is required.

Breathlessness is one of the most common symptoms in people with long COVID. Many factors can contribute, including damage to the lungs and supporting tissues, impact on the nervous system and other ongoing symptoms such as fatigue and cough. Anxiety around breathing can exacerbate breathlessness and all these factors can influence how people breathe after COVID-19 infection, potentially worsening their quality of life. As of January 2022, it is estimated that 1.5 million people in the UK may be experiencing long COVID symptoms.

Lead author of the study, Dr Keir Phillip, Clinical Research Fellow at the National Heart and Lung Institute at Imperial College London, said: 

“We urgently need evidence-based treatments and interventions for people with long COVID, which currently affects approximately 1 in 50 people in the UK. Our study suggests that arts-in-health interventions can be effective tools for carefully selected participants, especially when successfully integrated with clinical services.”

 “Our study suggests that the improvements in symptoms experienced by participants, resulted from both practical breathing techniques learnt, but also the creative, humane, and positive way the programme is delivered.”

Senior author, Dr Sarah Elkin, consultant lead for the programme and a respiratory consultant at Imperial College Healthcare NHS Trust, said: 

“As we continue to recover from the impact of the pandemic, it’s vital we find ways to support people with long COVID who are experiencing debilitating symptoms long after recovering from their initial COVID-19 infection. It is extremely important to build an evidence base for programmes such as ENO Breathe, so we can continue to understand how best to support people with long COVID and make improvements that can lead to better outcomes.”

Professor Nicholas Hopkinson, co-senior author and Professor of Respiratory Medicine at Imperial College London, said:

“Breathlessness is one of the most common symptoms that people with long COVID experience. The ENO Breathe programme is designed to help people with the condition to learn how to control their breathing better. Our research shows that it is effective, and the programme has already benefitted more than 1000 people recruited from post-COVID clinics across the UK”

Dr Harry Brunjes, Chair of the English National Opera, said: 

“We are extremely proud that ENO Breathe has been evidenced to aid the recovery of the people with long-covid it has been designed to help. Research like this demonstrates the enormous benefit the arts can have when applied in a medical context. We’re enormously grateful to our partners at Imperial College Healthcare NHS Trust for their dedicated work in developing this programme with us, and to Imperial College’s phenomenal team for their painstaking research.”

James Sanderson, CEO of The National Academy for Social Prescribing (NASP), said: 

“At NASP we believe that social prescribing can transform people’s health, so it is exciting to see clinical evidence published which demonstrates the effectiveness of a social prescribing programme. We are delighted to be able to support ENO’s ‘Breathe’ classes that are improving the lives of hundreds of people living with long COVID.”

Trial participants were all recovering from COVID-19 with ongoing breathlessness, either with or without associated anxiety, and had been referred from post-COVID assessment clinics after appropriate investigations and treatment. The majority of participants (81 per cent) were female, which is broadly representative of the wider population of patients with long COVID. 

Participants were split into two groups. One group (74 people) took part in the six-week ENO Breathe programme and a control group (76 people) continued with their usual care as directed by their post-COVID assessment clinic. Both groups were assessed after six weeks, when the control group were then also offered the opportunity to take part in the programme.

The researchers collected information about participants’ health and wellbeing via online questionnaires, and used focus groups and feedback questions to assess participant experience. They measured mental and physical components of a validated ‘Health-Related Quality of Life’ tool that assesses key indicators of quality of life, including difficulties resulting from health problems, social impacts, pain and impact on daily activities. The researchers also assessed other disease impacts including breathlessness, anxiety, and a range of other symptoms.

There were also three common qualitative themes regarding participant experience - an improvement in symptoms, a feeling that the programme complemented the care they were receiving, and that singing and breathing suited their needs.  



1.About ENO Breathe

ENO Breathe is an award-winning breathing and wellbeing programme developed specifically for people recovering from COVID-19, who are still suffering from breathlessness and associated anxiety. Delivered by the English National Opera in collaboration with Imperial College Healthcare teams entirely online, the programme focuses on breathing re-training through singing.

Following an initial six-week pilot from September to November 2020, ENO Breathe was rolled out nationally to participating healthcare networks. The programme has now helped over 1,000 participants and the ENO are helping to advise other organisations looking to set up similar programmes globally.

ENO Breathe is not a choir or singing group. It is a social prescribing (non-clinical) intervention that uses singing techniques to aid recovery from COVID-19. Participants must be referred by the post-COVID assessment clinic.

ENO Breathe offers participants:

- An initial one-to-one online conversation with ENO Breathe session leaders to discuss participants’ suitability for the programme, explain what the programme involves, and answer any questions participants might have.

- Six weekly group online workshop sessions, led by a professional singer from the ENO encourage participants to take part in exercises and activities specifically designed to support breathing control, providing tools for self-management of breath and anxiety.

- Access to bespoke online digital resources, designed to support participants between sessions. These include exercises, song sheets and audio and video materials, especially recorded by the ENO for participants on the programme.

- Access to post-programme weekly drop-in sessions, if participants wish to revisit exercises and songs in a friendly and relaxed environment with other participants who have also completed the programme.

ENO Breathe is recipient of the Royal Philharmonic Society’s (RPS) 2021 Impact Award.


2.About Imperial College Academic Health Science Centre (AHSC) 

The AHSC is a partnership between Imperial College London, The Institute of Cancer Research (ICR) Imperial College Healthcare NHS Trust, Chelsea and Westminster NHS Foundation Trust and the Royal Marsden NHS Foundation Trust, based in West London. 

Established in 2007, it was the first AHSC to be created in the UK and was formally designated by the Department of Health in 2009. 

The partnership brings together multi-disciplinary research and education from across all faculties at the College with the resources and critical mass of the three Trusts to advance discovery and innovation within healthcare. 

The purpose of Imperial College AHSC is to utilise excellence in research and education to transform health outcomes, and support the UK's globally competitive position in healthcare related industries by increasing societal and economic gain. 

The AHSC is nested within Imperial College Health Partners, the Academic Health Science Network for North West London, which will ensure that discoveries and innovations are applied on a national and global scale. 

3. About Imperial College London

Imperial College London is one of the world's leading universities. The College's 16,000 students and 8,000 staff are expanding the frontiers of knowledge in science, medicine, engineering and business, and translating their discoveries into benefits for society. 

Founded in 1907, Imperial builds on a distinguished past - having pioneered penicillin, holography and fibre optics - to shape the future. Imperial researchers work across disciplines to improve health and wellbeing, understand the natural world, engineer novel solutions and lead the data revolution. This blend of academic excellence and its real-world application feeds into Imperial's exceptional learning environment, where students participate in research to push the limits of their degrees. 

Imperial collaborates widely to achieve greater impact. It works with the NHS to improve healthcare in west London, is a leading partner in research and education within the European Union, and is the UK's number one research collaborator with China. 

Imperial has nine London campuses, including its White City Campus: a research and innovation centre that is in its initial stages of development in west London. At White City, researchers, businesses and higher education partners will co-locate to create value from ideas on a global scale. 

Imperial College London is a world-class university with a mission to benefit society through excellence in science, engineering, medicine and business.

4.  About Imperial College Healthcare NHS Trust

Imperial College Healthcare NHS Trust is one of the largest hospital Trust's in England, providing acute and specialist healthcare for a population of nearly two million people. The Trust has five hospitals - Charing Cross, Hammersmith, Queen Charlotte's & Chelsea, St Mary's and The Western Eye as well as community services.

 5. About the English National Opera

The English National Opera is the national opera company dedicated to one simple aim: making opera for everyone. We sing in English to be accessible to the widest possible audience, as well as offering free tickets for under 21s, and for as little as 10 pounds for everyone else. We create opera that feels different, theatrical and creatively daring and have been doing this to an internationally recognised standard since being founded in 1931 as Sadler’s Wells Opera.

From the world’s first large-scale drive-in opera, creative projects with young people, and TV broadcasts on BBC Two and Sky Arts, we strive to be bold and adventurous in everything we do. We take seriously our role of not just producing innovative work, but also employing the arts as a catalyst for social good. We have partnered with Imperial College Healthcare NHS Trust to develop ENO Breathe, a social prescribing intervention that provides crucial support to people recovering from COVID-19. So far, 70 NHS Trusts are signed up to refer participants to the programme.

We are passionate about making opera more inclusive and representative of the society in which we live, actively recruiting musicians and singers from an ethnically diverse background in our Orchestra and Chorus Fellowships and Director Observership programme for emerging directors.  

Showcasing the wealth of nationwide talent is fundamental to the ENO’s vision. Our talent development programmes continue to nurture the careers of singers (the ENO Harewood Artist programme), conductors (the ENO Mackerras Fellowship), musicians (ENO Evolve) and critics (ENO Response). 

We believe that positive change for the industry also comes from removing barriers to access. We offer free tickets to under 21s to every performance and at every level of the theatre, and have extended discounts for under 35s. We have increased our number of relaxed performances, designed to be more accessible for those who may benefit from a more relaxed environment at the theatre.

ENO is for everyone, and always will be.