In individuals who experience persistent symptoms after having had a COVID-19 infection, use of the online breathing and well-being program called English National Opera (ENO) Breathe can improve the mental component of health-related quality of life (HRQoL), as well as elements of breathlessness. This was among clinical trial findings recently published in The Lancet Respiratory Medicine.

Realizing that few evidence-based interventions for long COVID exist but that holistic approaches that support recovery are widely advocated, investigators for the current study sought to evaluate whether use of the ENO Breathe program would improve HRQoL in individuals with ongoing COVID-19–related breathlessness. The researchers conducted a parallel-group, single-blind, randomized controlled trial ( Identifier: NCT04830033) of patients who had been referred from 1 of 51 United Kingdom-based collaborating long COVID clinics.

Eligibility requirements for study participation were as follows: (1) aged ≥18 years; (2) recovering from COVID-19 and experiencing ongoing breathlessness, with or without anxiety; (3) enrolled ≥4 weeks after onset of symptoms; (4) had internet access with an appropriate device; and (5) deemed clinically suitable for participation by a collaborating COVID-19 clinic. After undergoing clinical evaluation, all potential participants received a unique online portal code.

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Participants were randomly assigned in a 1:1 ratio to either immediate participation in the ENO Breathe program or to usual care. Those in the ENO Breathe group participated in a 6-week online breathing and well-being program, which was developed specifically for individuals with long COVID who were experiencing breathlessness. ENO Breathe focused on breathing retraining with the use of singing techniques. Participants enrolled in the deferred group received usual care until the time that they exited the study.

The primary study outcome, which was evaluated in the intention-to-treat population, was change in HRQoL, which was assessed via use of the RAND 36-item short form
(SF-36) survey instrument mental health composite (MHC) and physical health composite (PHC) scores. Secondary outcomes included chronic obstructive pulmonary disease assessment test score; visual analog scales (VAS) for breathlessness; and scores on the dyspnea-12, the generalized anxiety 7-item scale, and the Short-Form 6-Dimension health index (a measure of functional health and well-being).

A total of 158 participants were recruited and randomized between April 22 and
May 25, 2021, with 8 individuals ultimately excluded. Thus, 150 patients were assigned to a treatment group — 74 to the ENO Breathe group and 76 to the usual-care group.

Results of the study showed that individuals in the ENO Breathe arm had an improvement in SF-36 MHC scores compared with those in the usual-care arm (regression coefficient, 2.42; 95% CI, 0.03-4.80; P =.47); however, the SF-36 PHC scores did not differ significantly between the groups (regression coefficient, 0.60;
95% CI, –1.33 to 2.52; P =.54).

A statistically significant difference was reported in VAS breathlessness (ie, running) score between the treatment arms, favoring the ENO Breathe arm (regression coefficient, –10.48; 95% CI, –17.23 to –3.73; P =.026). Most of the other secondary outcome measures were numerically better in the ENO Breathe group than in the usual-care group, but none of these differences were statistically significant.

When experiences of the ENO Breathe participants were analyzed, 3 key themes were identified: (1) symptom improvements; (2) feeling that the program was complementary to standard care; and (3) the suitability of an approach to care using singing and music to address participant needs.

Limitations of the current study include the fact that given the nature of the ENO Breathe intervention, the use of double blinding was not possible. Moreover, additional measures to further define participants might have been useful, including objective physical performance measures, actigraphy, baseline lung function testing, and assessment of participants’ breathing patterns.

The investigators concluded that research into other related approaches could prove valuable, along with improved characterization of long COVID subgroups to identify those most likely to benefit from the use of interventions.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Philip KEJ, Owles H, McVey S, et al. An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial. Lancet Respir Med. Published online April 27, 2022. doi:10.1016/S2213-2600(22)00125-4

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