ENO Breathe proven to improve long COVID symptoms in major study published in The Lancet Digital Health

A new study published today, Thursday 7 May, in The Lancet Digital Health has found that ENO Breathe, an award-winning online breathing and wellbeing programme developed by English National Opera (ENO) in collaboration with clinicians from Imperial College Healthcare NHS Trust, delivers significant improvements for people living with long COVID. The research, carried out by Imperial College London, demonstrates measurable benefits in quality of life, breathlessness, anxiety, and respiratory symptoms, providing robust clinical evidence for the programme’s impact on long-term respiratory and mental wellbeing.

ENO Breathe is a free, live six-week online breathing and wellbeing programme available nationally through referrals from partnered NHS Trusts. Using singing techniques with a particular focus on lullabies from around the world, the programme aims to improve breathing, wellbeing and quality of life for people living with long COVID and related breathlessness.

The programme combines breathing retraining, singing techniques and wellbeing support, delivered through live online group sessions led by specially trained ENO vocal specialists and facilitators, alongside flexible digital resources that participants can access in their own time. Designed to complement clinical care, ENO Breathe accepts participants following assessment and referral through specialist healthcare pathways, ensuring it integrates safely and effectively alongside NHS specialist services supporting patients with post Covid symptoms.

Since launching in September 2020, the programme has expanded to take referrals from 85 NHS partners nationally and has supported more than 4,829 participants to complete the programme. The programme continues to reach patients with breathlessness from long COVID and is now also open to people experiencing similar post-viral symptoms. ENO Breathe’s ongoing evaluation shows strong health and wellbeing outcomes: 80% of participants reported improved levels of breathlessness, 73% said their anxiety levels had improved, and 80% experienced an improvement in their general wellbeing. Overall, 87% of participants said that ENO Breathe had a positive impact on their general wellbeing.

Janardhan Rao is a recent participant in the ENO Breathe programme, having joined to support his recovery from long COVID and ongoing respiratory health. He is also an Orthopaedic Consultant in Chester and an Honorary Clinical Lecturer at the University of Liverpool.

Janardhan Rao comments: “I have been fortunate enough to be referred into ENO Breathe and I found it transformational. As a doctor who contracted COVID-19 early on, in my line of work, the lasting effects of the disease have been devastating. I had to stop working as I had real difficulty catching my breath. I could not speak for any length of time and was exhausted continuously.

The ENO Breathe programme helped me get back to work, in ways that I did not expect. I was not a singer, so I did not think that it would be for me. I was breathless all the time, but with the weekly programme of mindful breathing exercises and simple lullabies, I found that I could speak in sentences again. As my breathing improved, I found that I had the energy to go back to work. I am so grateful for this programme.”

The newly published study analysed outcomes from 1,438 participants referred through 51 NHS long COVID services across England, making it one of the largest real-world evaluations of a creative health intervention for long COVID breathlessness to date. Participants who completed the six-week programme experienced clinically meaningful improvements across multiple validated health measures, with 61% achieving clinically important improvements in breathlessness. Engagement levels were high, and no serious adverse events were reported.

These findings build on earlier evidence from a Randomised Controlled Trial (RCT) published in The Lancet Respiratory Medicine in April 2022, further strengthening the clinical evidence base for ENO Breathe and its potential for integration at scale within NHS services.

Lead author of the study, Dr Keir Philip, Clinical Lecturer at the National Heart and Lung Institute at Imperial College London and an Honorary Consultant in Respiratory and General Medicine at Imperial College Healthcare NHS Trust, said:

“Long COVID is still a really important health issue, negatively impacting quality of life and limiting what people can do, and this study shows that ENO Breathe can improve a range of symptoms in the real world, not just in a clinical trial. The participants experienced important improvements in respiratory symptoms, mental health, and quality of life, all while doing something they really enjoyed. Central to this programme is that it treats people as people, not just numbers, and capitalises on their pleasure in joining in with others.”

Dr Sarah Elkin, medical lead for ENO Breathe and Honorary Clinical Senior Lecturer Imperial College, said: “These findings provide robust evidence that ENO Breathe can deliver meaningful improvements in both physical and psychological outcomes for people living with long COVID. What is particularly encouraging is the programme’s ability to complement existing clinical care, offering patients a structured, accessible way to regain control of their breathing and overall wellbeing. This study highlights the important role that evidence-based, multidisciplinary approaches – including creative health interventions – can play in supporting recovery at scale.”

Beth Warnock, Director of Engage, ENO’s learning and participation department, said:
“Six years on from the pandemic, we are extremely proud that ENO Breathe has been supported by this important evidence, demonstrating the real impact the programme has had for people living with long COVID. These findings strongly validate what our participant data has consistently shown since the programme began. Research like this continues to show the powerful role the arts can play within healthcare, particularly when delivered in close partnership with clinicians. We are incredibly grateful to our partners at Imperial College Healthcare NHS Trust, for their expertise and collaboration in both developing and rigorously evaluating ENO Breathe. Building on this evidence, we now look forward to expanding ENO Breathe further to support people living with COPD and asthma.”

Suzi Zumpe, Creative Director of ENO Breathe, said:
“Creativity is key to our approach: participants don’t just learn techniques, they discover what works for them. By using imagery and imagination, we help people get out of their own way, unlocking a new perspective and restoring a sense of agency. Singing lullabies builds emotional connections with the wider set of ideas and practices that make up ENO Breathe. Participants finish sessions with a calming song in their hearts and a positive connection to tools, making them more memorable, more meaningful and more usable. It is incredibly encouraging to see this approach now robustly validated by a major study published in The Lancet Digital Health, evidencing that ENO Breathe can significantly improve symptoms and quality of life for people living with long COVID.”

Through 2026-27, ENO will pilot an expanded version of the ENO Breathe programme in both London and Greater Manchester, supporting people living with chronic respiratory conditions, including COPD and asthma. For the duration of the pilot, referrals will be accepted only via partnered NHS services in these two regions. In Greater Manchester, the programme is part of the Greater Manchester Creative Health Place Partnership led by NHS Greater Manchester and the Greater Manchester Combined Authority. Future expansion will be considered following evaluation of the pilot. This next phase continues ENO’s commitment to creative health and evidence-based respiratory support for wider NHS integration.

In parallel, ENO Breathe continues to accept referrals for people experiencing ongoing breathlessness since having Covid-19, as well as those with similar post-viral symptoms. The programme demonstrates ongoing clinical relevance and capacity to operate at scale. NHS services and clinicians are encouraged to refer eligible patients, with the programme ready to meet growing demand and support recovery alongside clinical care.

The study is published in The Lancet Digital Health, the world’s the most prominent publishing venue in digital health, and can be read in full here: www.thelancet.com/journals/landig/article/PIIS2589-7500(26)00011-7/fulltext

The previously published results of the RCT in The Lancet Respiratory Medicine, the world’s top-ranking respiratory medicine journal, can be read in full here: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00125-4/fulltext

To find out more about the ENO Breathe programme, please visit the ENO Breathe homepage