28/03/2025 ENO Breathe: supporting people with Long Covid through breathing and singing techniques

ENO Breathe exemplifies an innovative and effective approach to supporting individuals with long COVID. By addressing both physiological and psychological aspects of recovery, it uses transferable skills from singing techniques, offering a holistic model that could inform future health and well-being initiatives.

The COVID-19 pandemic has left a significant number of individuals experiencing prolonged symptoms, commonly referred to as long COVID. Among these symptoms, breathlessness and associated anxiety are prevalent, impacting patients' quality of life and daily functioning. In response to this emerging health challenge, the English National Opera (ENO), in collaboration with Imperial College Healthcare NHS Trust, developed ENO Breathe - a breathing and wellbeing programme designed to support the recovery of those affected by long COVID. 

A Randomised Controlled Trial (RCT) conducted by researchers at Imperial College London evaluated the efficacy of the ENO Breathe programme. The study involved 150 participants, with 74 individuals participating in the ENO Breathe programme and 76 receiving usual care. The findings, published in The Lancet Respiratory Medicine, revealed that ENO Breathe participants experienced a 10.48-point reduction in breathlessness during physical activity compared to the usual care group. Additionally, there was a 2.42-point improvement in the mental component of quality of life among ENO Breathe participants. Further analyses indicated that participants who attended all sessions reported improvements in respiratory symptoms, reduced anxiety, and greater enhancements in quality of life. For instance, 40% of ENO Breathe participants experienced a five-point improvement in mental quality of life, compared to 17% in the usual care group.

Beyond the RCT, participant feedback has been overwhelmingly positive. According to programme evaluations:

• 94% of participants stated that ENO Breathe met their expectations.
• 98% would recommend the programme to others experiencing long COVID symptoms.
• 80% reported improvements in breathlessness.
• 73% noted reduced anxiety levels.
• 80% experienced enhanced general well-being.
• 87% felt that ENO Breathe had a positive impact on their overall well-being.

Several factors have contributed to the success of the ENO Breathe programme:

• Unique collaboration between arts and healthcare: Combining medical and artistic expertise, the programme has been developed in partnership with a clinical team at Imperial College NHS Trust, providing clinical input in its design whilst remaining non-clinical in its delivery. 
• Defined referral criteria and pathway: A medical referral criteria and pathway through long Covid services (89 partnered services) was designed to ensure participant safety, maximise the programme’s impact and support effective referrals. 
• Accessibility and inclusivity: The online delivery model ensures that participants from various regions can access the programme. Its design accommodates individuals without prior singing experience, and aims to support individuals beyond the session time by providing easy to use digital resources, making it inclusive to different modes of learning.
• Positive and caring approach: From the content of the sessions, the music chosen (lullabies) to the communication with participants, everything is geared towards providing a caring and positive environment. Whilst the programme provides physiological explanations to the exercises, the focus is on connecting emotionally. As a result, people feel seen, understood and connected.
• Rooted in evaluation: Both qualitative and quantitative evaluation have been at the heart of the programme’s development. High satisfaction rates and positive feedback underscore the programme's effectiveness and its meaningful impact on participants' lives. The Randomised Controlled Trial also played a crucial role in the success of the ENO Breathe programme by providing rigorous, evidence-based validation of its effectiveness.

Current challenges for the programme include:

·      Changes to referral pathways: The current changes with the NHS Long Covid services being decommissioned and merging with other existing services are having an impact on our referral pathway and its effectiveness.

·      Funding: The ENO Breathe programme has been funded by Trusts, Foundations and private donors but has to date not received funding from the NHS, making it more challenging for the programme to be fully imbedded into NHS frameworks. 

The ENO is now also partnering with NHS GM Integrated Care and Greater Manchester Combined Authority to develop and pilot a new iteration of the programme. This will see the project expand from a focus on Long Covid to support people who are living with diagnoses of other respiratory conditions, such as COPD (Chronic Obstructive Pulmonary Disease) and Asthma.

In addition, further work shaping the health economic evaluation of the programme will be undertaken to make a stronger case for funding and commissioning, and a self-guided offline version of the programme, which will be open and accessible to all, is also being developed and tested for wider roll-out.