Improving lung health one song at a time

Respiratory specialist Dr Anna Moore and volunteer coordinator Catherine Furlong explain how singing can improve lung health for people with chronic respiratory disease and how their Singing for Breathing group is benefiting patients in London.

Singing for lung health – group-based singing to help improve lung function in people with respiratory disease – started in the NHS in 2007 with pilot groups in Brighton and at the Royal Brompton Hospital. The pilot took inspiration from a project in Oldham called ‘Bronchial Boogie’ in which children with asthma were taught to play brass instruments to improve their respiratory health and self-esteem.

As more groups sprang up around the country, in 2014 the British Lung Foundation (BLF; since merged with Asthma UK to become Asthma+Lung UK) commissioned a training programme for singing leaders to provide breathing exercises specially designed to improve the breathing of those with chronic respiratory diseases like COPD and asthma.

Why singing?

Though the physiological mechanisms are not fully understood, a number of studies have identified potential ways in which singing supports breathing.

These include: control of expiratory flow using controlled muscle activity; alteration of the chest wall and abdominal muscle contribution to breathing, which allows the diaphragm to be engaged; improving inspiratory strength; helping with airway clearance; and improving posture and balance.

Our sessions have been shown to be comparable to moderate physical activity in intensity. For people living with chronic respiratory disease, all these features add up to a fantastic therapeutic activity which helps reduce breathlessness.

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The gold standard treatment for COPD, as well as smoking cessation and flu vaccinations, is pulmonary rehabilitation (PR). This is an exercise-based intervention which typically runs over 8 weeks, with participants attending twice per week. PR has a strong evidence base for reducing breathlessness, increasing physical activity and reducing the risk of exacerbations, in addition to reducing depression and anxiety.

Despite this, PR is underused as a resource, partly due to a low referral rate and inconsistent commissioning that means that services are not available equitably across the UK.  People living with COPD are also often fearful of taking part in exercise due to breathlessness, and even if they agree to a referral, they may also experience difficulties getting to the sessions.

Singing for lung health can potentially complement or offer an alternative to PR, bringing more holistic and social elements to breathing exercises.

How our singing group is benefiting patients

While not everyone enjoys singing, the approach to singing for improving lung health focuses more on making it an activity which is pleasurable for most people, and it is an inherently sociable activity.

In fact, we find that one of the most important aspects of singing for lung health is the social connection which happens at a singing for breathing group, and the joy and laughter that comes from taking part.

Our group at Barts Health Trust, which covers Tower Hamlets, Newham and Waltham Forest, started up in 2017 with a grant from the Barts Health Charity to recruit a BLF singing teacher. No formal referral is required for people to join our group, known as Singing for Breathing (Royal London Hospital).

It’s important to note that the singing groups are not choirs, and no previous singing experience is required. Individuals can self-refer, but most referrals come from medical and allied professionals such as specialist asthma physiotherapists. The sessions last an hour, with the first half spent on breathing exercises and the remaining half on singing popular, folk and world songs, enabling participants to put the exercises into practice. Our group runs sessions online every week and hybrid – both in-person and online – every other week.

We regularly survey participants and always receive overwhelmingly positive responses – the following is a selection of recent feedback:

‘Session is a real confidence booster and fun.’

‘It’s beneficial to be with people with similar conditions and to know you have the techniques to deal with any breathing issues.’

Related Article: Practice dilemma: How can I diagnose asthma without access to tests?

‘Meeting people in a relaxed and welcoming setting has been positive and is in my calendar under “health” and “my time”.’

An increasing amount of evidence demonstrates that singing can improve the wellbeing of patients with lung disease, both with their breathing and mental health.

How can my patients get involved?

Asthma+Lung UK has a dedicated page on their website where those interested can learn more about singing for lung health across the UK and find their local group.

In some areas, singing groups have had to start charging participants a small fee. Fortunately, our group at Barts remains free to attend, and we have recently won two years of funding from the National Lottery Community Fund.

However, most groups are free or very low cost to join and are open to patients with any form of chronic respiratory disease and their carer.

Tell your patients – all they need to bring to their local singing group is enthusiasm!

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Dr Anna Moore is specialty doctor in respiratory medicine at Barts Health NHS and Catherine Furlong is volunteer coordinator at Singing for Breathing, Royal London Hospital

Sources and further informaton

• Lewis A, Elmslie K, Philip J et al. The physiology of singing and implications for ‘Singing for Lung Health’ as a therapy for individuals with chronic obstructive pulmonary disease. BMJ Open Respir Res 2021;8:e000996
• Taskforce for Lung Health. Pulmonary rehabilitation resources.
• Asthma and Lung UK. What happens in a singing for lung health session?
• Singing for Breathing (Royal London Hospital) video (from 2019, in person only): Singing For Breathing