Eno Breathe class on Zoom

How opera techniques are helping people with long COVID breathe easier

​​​​​​​Around the world, few treatments exist for the countless numbers of people who develop long COVID-19. In the UK, where more than a million people are estimated to be in this situation, a group of medical specialists and professional opera singers have been examining whether an age-old performance practice can help address one of the most common, debilitating symptoms: breathlessness. 

The World

At an ENO Breathe session image, patients do a shoulder stretch.

Courtesy of the English National Opera

Abigail Kelly, an opera singer in England, led a Zoom class where she asked everyone to imagine a “magical” doughnut and then pretend to smell it.

“Mmmmmmm,” she sang, with a long rolling pitch.

She encouraged the students, all of whom are long COVID-19 patients, to make similar, exaggerated responses (on mute).

The class, which took place earlier this year, is part of a six-week online program in the UK called ENO Breathe in which opera professionals instruct patients on everything from breathing meditations and posture exercises to singing gentle lullabies.

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“Using singers, first of all, as session leaders is fantastic because we have been so obsessed with our breathing for the majority of our careers,” said Kelly, a soprano who has played leading roles such as in “The Marriage of Figaro,” with the English National Opera. “I am totally obsessed with my breathing.”

Few proven treatments exist for long COVID-19, an umbrella term for conditions that can continue for weeks, months or more after an initial infection, and which can’t be explained by anything else.

In the UK, more than a million people are estimated to be in this situation.

That includes Brent Hinks, who got seriously ill with COVID-19 at the start of the pandemic.

Then, certain symptoms lingered well after the infection. The 58-year-old’s memory got foggy, he tired easily, and he’d wake up in the middle of the night feeling like he was in a tunnel that was collapsing on his chest.

“I’d just gasp, absolutely gasping,” said Hinks, who lives just outside of Bristol, England, and teaches college students struggling with English. “It’s terrifying, and you’d think ‘I can’t breathe. I’m going to die. I don’t know what to do.'”

Clinicians specializing in long COVID-19 refer patients to the program, who then do a one-on-one with an instructor to ensure it’s the right fit. Hinks directly inquired about ENO Breathe after hearing about it and took the class this past winter. Through the sessions, he said, he realized that he’s not alone. And, when he experiences his chest caving in and feels like he can’t breathe, he pauses now instead of panicking.

“I think, 'right, now, what did they tell me?' And I’ll put my hands behind my head or something, and I breathe,” he said.

Brent Hinks, long COVID patient, England

“I think, 'right, now, what did they tell me?' And I’ll put my hands behind my head or something, and I breathe,” he said.

He may hum a lullaby from the course too (his favorite is “Summertime” from “Porgy and Bess”).

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He doesn’t think his long COVID-19 or breathlessness is going away. But he can better manage it: “I think, you know what, I’m not going to die, I’ll be fine. I know what it is now. I know how to deal with it.”

‘A vicious cycle’

Breathlessness can have physical and psychological triggers, according to Dr. Keir Philip, a fellow at the National Heart and Lung Institute at Imperial College and a researcher on the opera project.

For patients with long COVID-19, breathlessness may have its roots in physical changes to the hearts, lungs or muscles. Researchers are still trying to understand what exactly is going on. When it goes wrong, for whatever reason, it can be hard for someone to breathe normally again.

“So, as we become anxious about being breathless, and as we change the way in which we breathe in a less efficient way, that actually creates a bit more of a more vicious cycle in which people can become more breathless,” Philip said.

Dr. Keir Philip, a fellow at the National Heart and Lung Institute at Imperial College and researcher on the opera project

“So, as we become anxious about being breathless, and as we change the way in which we breathe in a less efficient way, that actually creates a bit more of a more vicious cycle in which people can become more breathless,” Philip said.

ENO Breathe tries to address that, he said, through exploring the way that people breathe — their pattern and which muscles they’re engaging with — and how it affects them psychologically.

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“We can try and reduce the amount of anxiety which breathlessness has caused and is causing, and also improve the efficiency in the way people are breathing,” Phillips said.

Click below to listen to a lullaby (lodelo) performed by Suzi Zumpe, singing specialist and creative director of ENO Breathe

From pilot to over a thousand participants

The idea for a breath retraining and wellness program came in the summer of 2020, when performance stages went dark and it became clearer that many patients continued to have post-COVID-19 symptoms.

English National Opera, one of Britain’s main opera companies, connected with respiratory specialists at Imperial College Healthcare in London and came up with the online course, first piloting it with just a handful of patients.

They then put the intervention to the highest test: conducting a randomized control trial; 74 people with long COVID-19 participated in the course and 76 people with long COVID-19 engaged only with regular clinical care.

Through surveys, they found that the course didn’t have a major impact on people’s physical health, but overall, participants reported notable improvements in their quality of life and mental health, and to a smaller degree, their breathlessness.

Few proven treatments exist for long COVID-19, which can refer to a variety of different conditions. But the need is growing: a new analysis from the US Centers for Disease Control and Prevention suggests that more than a third of people may experience at least one condition, whether that’s heart or breathing problems, at least a month after being infected.

Hannah Davis, co-founder of the Patient-Led Research Collaborative, a group of long COVID-19 patients from around the world, studies their conditions.

While she is glad that ENO Breathe may be helpful for some patients, she said that what’s most needed is more research into all of the underlying physical causes of long COVID-19 symptoms and their treatment.

“From what we know about post-viral illnesses, even though an opera and singing program may help some components like mental health and connecting with others, and community support, it feels very optimistic to think of it as a treatment for the physical issues that long COVID brings,” she said.

More than a thousand people have since taken part in the ENO program. It’s now being replicated in Wales and organizers said they’ve received interest from more than two dozen countries, from Japan to Peru.