Online Breathing and Wellbeing Programme (ENO Breathe) for Long COVID

Philip, K. E., Owles, H., McVey, S., Pagnuco, T., Bruce, K., Brunjes, H., … & Hopkinson, N. S. (2022). An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial. The Lancet Respiratory Medicine, 10(9), 851-862.

Rationale

Long COVID can cause persistent breathlessness, anxiety, and reduced quality of life in a substantial portion of people who develop COVID-19 (Soriano et al., 2022).

However, there is currently a lack of evidence-based interventions to address these long-term sequelae (Buttery et al., 2021; Crook et al., 2021).

Expert consensus recommends personalized, holistic rehabilitative approaches (Greenhalgh et al., 2020) and singing-based interventions have previously shown benefits for lung health and quality of life in other respiratory conditions (Lewis et al., 2016).

Therefore, the aim of this randomized controlled trial was to assess the effectiveness of an online breathing and wellbeing program (ENO Breathe) for improving HRQoL and breathlessness in people with long COVID.

Method

This was a parallel-group, single-blind, randomized controlled trial. It compared ENO Breathe, a 6-week online breathing and wellbeing program, to usual care in people with long COVID experiencing breathlessness.

The primary outcome was change in HRQoL at 6 weeks, assessed by the RAND 36-item short form survey. Secondary outcomes included breathlessness measures.

Qualitative data on participant experiences was also collected.

Procedure

Participants were referred from collaborating long COVID clinics and randomly assigned 1:1 to the ENO Breathe or usual care group.

The ENO Breathe program was a 6-week online breathing and wellbeing intervention for people experiencing long COVID symptoms, particularly breathlessness and anxiety. The program consisted of several components:

1. One-to-one session: Each participant had an initial 20-minute online session with an ENO vocal specialist to discuss program suitability, expectations, and to address any questions or technical concerns.

2. Weekly online group sessions: Participants attended weekly 1-hour online group sessions led by an ENO vocal specialist. These sessions included:

• Warm-up exercises for body and breath
• Breathing control techniques
• Guided relaxation
• Singing lullabies
• Sharing of experiences with other participants

3. Online resources: Participants had access to a variety of online resources to support their learning and practice between sessions. These included:

• Recorded lullabies to sing along with
• Instructional exercise videos
• Downloadable music playlists

4. Homework: Each week, the vocal specialists provided participants with specific exercises to practice and focus on between sessions.

5. Emails and support: Participants received regular emails (at least 3 per week) encouraging engagement with the online resources, providing session reminders and recaps, and offering a direct line of communication with the ENO Breathe team.

6. Focus group: At the midpoint of the program (week 3), participants were invited to a focus group to share experiences and provide feedback.

The singing, breathing and relaxation techniques were taught incrementally over the 6 weeks, with the intention of equipping participants with tools for self-management of their symptoms in daily life. Lullabies were selected as the core musical material for their calming, soothing qualities and simplicity.

Although the specific techniques were taught in a standardized manner, the program was tailored to each individual’s needs and capabilities through personalized advice and feedback from the vocal specialists. The group format and interactive elements aimed to foster a sense of connection and peer support.

After the 6-week trial period, the program remained available to participants through ongoing “Twilight sessions” held every 2 weeks. However, these were not a formal part of the research intervention.

Sample

150 participants with long COVID and ongoing breathlessness were included (74 ENO Breathe, 76 usual care). Mean age was 49, 81% were female, and 82% were of White ethnicity. Symptom onset was a mean of 320 days before enrollment.

Measures

• RAND 36-item short form survey (SF-36) – HRQoL measure
• Chronic Obstructive Pulmonary Disease Assessment Test (CAT) – respiratory health status
• Visual Analogue Scales (VAS) – breathlessness severity
• Dyspnoea-12 questionnaire – breathlessness severity
• Generalised Anxiety Disorder 7-item scale (GAD-7) – anxiety symptoms

Statistical measures

The primary analysis compared outcomes between groups using linear regression models adjusted for baseline scores.

Additional analyses examined responder rates and a modified per-protocol population. Thematic analysis was conducted on the qualitative data.

Sample size of 108 provided 90% power to detect a 5-point difference in SF-36 scores.

Results

The ENO Breathe group had a significantly greater improvement in the SF-36 mental health composite score compared to usual care (adjusted mean difference 2.42, p=0.047).

There was no significant difference in the physical health composite.

The ENO Breathe group had a greater improvement in the VAS breathlessness (running) score (adjusted mean difference -10.48, p=0.0026).

Other secondary outcomes were numerically better with ENO Breathe but did not reach significance. 22% of ENO Breathe participants withdrew compared to 7% with usual care.

Sensitivity analyses accounting for this did not substantially change results.

Qualitative Findings

The qualitative component of the study explored participants’ experiences with the ENO Breathe program.

Data was collected through focus groups, survey responses, and email correspondence from 52 participants in the ENO Breathe group and 129 participants across both groups.

Thematic analysis identified three key themes:

1. Improvement in symptoms:

• Participants reported improvements in breathlessness (especially on exertion), anxiety, sleep, concentration, and voice.
• These improvements were attributed to learning practical techniques for symptom management, the calming and enjoyable nature of the sessions, and a shift in how they perceived their condition.

2. Complementary to standard care:

• Participants felt the program addressed gaps in their usual care, particularly the lack of long COVID-specific interventions.
• The program’s holistic approach, continuity over multiple weeks, and focus on building connections were seen as key strengths.
• Many saw ENO Breathe as a valuable adjunct to medical management that catered to their multi-faceted needs.

3. Suitability of singing and music:

• Even those initially skeptical found the use of singing and music to be a highly appropriate and effective approach.
• The enjoyable, immersive nature of the musical activities allowed participants to engage with their breathing in a more positive, less conscious way.
• The emotional resonance and creative elements were seen as uniquely suited to addressing both physical and psychological aspects of long COVID.

Participants also provided positive feedback on the program’s structure, the skill and empathy of the vocal specialists, and the sense of community developed within the groups. Many expressed a desire for the program to be more widely available.

However, a few participants did report challenges, such as fatigue or mild dizziness, though generally felt the benefits outweighed these issues. Some practical barriers around digital access and scheduling were also noted.

Insight

This study provides novel evidence that a singing-based online intervention can lead to clinically meaningful improvements in mental well-being and exertional breathlessness in people living with long COVID.

The holistic approach using singing techniques, music and breathlessness management strategies was able to support recovery in both mind and body.

Importantly, the program was perceived by participants to address gaps in clinical care in an accessible and enjoyable way, even among those initially skeptical of singing-based approaches.

The qualitative findings provide insight into potential mechanisms and may guide future development of rehabilitation strategies to meet the multi-faceted needs of this population.

The trial demonstrates a model for integrating such interventions into clinical pathways via specialist clinic referral. This helped ensure safety and appropriateness of participants.

However, the high withdrawal rate in the intervention group suggests some individuals had challenges maintaining engagement and not all derived benefit. Further research to identify responder characteristics will be valuable.

While previous studies have shown quality of life benefits from singing in other respiratory conditions, this is the first randomized trial to evaluate a music-based intervention in long COVID.

The results extend the evidence base for “arts-in-health” approaches to a novel population with a condition of rising global importance.

The study also adds to a small but growing number of clinical trials investigating treatment of long COVID, addressing the current evidence gap hampering clinical management.

Strengths

• Randomized controlled design enabling robust comparison to usual care
• Recruitment via specialist clinics ensuring appropriate medical evaluation
• Participant-relevant, validated outcome measures
• Adequately powered sample size based on clinically important differences
• Inclusion of qualitative evaluation to provide important context
• Pragmatic, ‘real-world’ intervention integrated with clinical services

Limitations

• Participants and providers could not be blinded due to the nature of the intervention
• The sample was predominantly female and White, potentially limiting generalizability
• There was a differential withdrawal rate between groups which could bias results, although sensitivity analyses were conducted to evaluate impact
• Potential barriers to participation, especially among minority groups, may not have been fully captured as such individuals were likely underrepresented
• The long-term durability of effects beyond 6 weeks was not assessed

Clinical Implications

The results suggest online group mind-body interventions using singing/music may be a valuable addition to the clinical management of long COVID.

Such programs could help address the mental health impact and breathlessness-related disability which are common and persist despite standard clinical care. The qualitative findings indicate high acceptability and perceived benefit for at least a subset of patients.

However, the intervention is not a panacea and requires a degree of digital access and engagement which will not be feasible for all. The high withdrawal rate, even in this self-selected sample, highlights the need to consider how to best target the intervention and support adherence.

The demographics of the sample also suggest potential equity considerations to ensure the accessibility of such programs.

Overall, the study provides important proof-of-concept that can inform the development and implementation of rehabilitation strategies for long COVID. Integration with specialist clinics may be an effective model to support medical management.

However, further research is needed to optimize content, identify predictors of success, and evaluate cost-effectiveness at scale.

Comparative studies with other modalities, longer-term follow-up, and more diverse samples will also be valuable.

While not a standalone solution, arts-in-health interventions are a promising adjunctive therapy for long COVID which warrant further attention and resourcing. They may fulfil an important role in the multi-pronged approach needed to address this significant global health challenge.

References

Primary reference

Philip, K. E., Owles, H., McVey, S., Pagnuco, T., Bruce, K., Brunjes, H., … & Hopkinson, N. S. (2022). An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial. The Lancet Respiratory Medicine, 10(9), 851-862.

Other references

Buttery, S., Philip, K. E. J., Williams, P., Fallas, A., McPhail, G., Billings, J., … & Hopkinson, N. S. (2021). Patient symptoms and experience following COVID-19: results from a UK-wide survey. BMJ Open Respiratory Research, 8(1), e001075.

Crook, H., Raza, S., Nowell, J., Young, M., & Edison, P. (2021). Long COVID—mechanisms, risk factors, and management. BMJ, 374.

Greenhalgh, T., Knight, M., A’Court, C., Buxton, M., & Husain, L. (2020). Management of post-acute COVID-19 in primary care. BMJ, 370.

Lewis, A., Cave, P., Stern, M., Welch, L., Taylor, K., Russell, J., … & Hopkinson, N. S. (2016). Singing for lung health—a systematic review of the literature and consensus statement. NPJ Primary Care Respiratory Medicine, 26(1), 1-8.

Soriano, J. B., Murthy, S., Marshall, J. C., Relan, P., & Diaz, J. V. (2022). A clinical case definition of post-COVID-19 condition by a Delphi consensus. The Lancet Infectious Diseases, 22(4), e102-e107.

Keep Learning

• How could the intervention be adapted or tailored for different demographics or cultural contexts? What barriers to accessing such programs might exist for underrepresented groups?
• What additional outcome measures or assessment timepoints would help further elucidate the mechanisms and durability of effects?
• How could the qualitative findings inform refinement of the intervention content, format or implementation to optimize acceptability and effectiveness?
• What factors might predict success with this intervention and how could these be efficiently assessed to target referrals? Conversely, what might characterize non-responders?
• How cost-effective is the intervention compared to standard care or other modalities? What economic evaluation would be needed to support sustainable implementation at scale?
• Could similar approaches be applied prophylactically or is specialist screening required? What would be the risks/benefits of wider access?
• How could the study design be enhanced with more objective physiological measures while balancing participant burden? What outcomes are most meaningful to patients?
• What insights from the program could be applied to holistic management of other post-viral syndromes? Are there common therapeutic processes?