Singing is a complex activity that involves phonation at the vocal fold level and resonation involving the tongue, soft palate, and larynx movements as well as breathing and postural support. Furthermore, it necessitates pitch adjustment as well as negotiating range and volume while learning melodies 'by ear.'

Given that singing commonly entails holding notes without taking extra breaths, the idea that singing could help people with respiratory illnesses may seem contradictory. Chronic Obstructive Pulmonary Disease (COPD) and asthma are the two most common lung conditions studied using singing approaches.

How can people with COPD or asthma sing in the first place or even benefit from it?

Singing for lung health

Singing for Lung Health (SLH) is a method that involves patients with respiratory diseases participating in singing groups in order to improve their condition. Singing for Lung Health (SLH) has over 100 groups in the UK, with many other groups globally. As SLH focuses on improving breath control and posture concerning respiratory disease, with songs serving as tools for this purpose, it differs from general singing activities. These precede the quality of singing and preparation for live public performance, although efforts to improve singing quality provide an essential impetus required for continued participation.

SLH groups involve posture and breath control components that are customized to lung disease, specifically airflow obstruction. Coughing is a common symptom of respiratory disease, and it may limit involvement in a traditional choir, whereas SLH groups provide a more tolerable environment for participants.

Singing has three main categories of benefits; psychological, physical, and social, although these may overlap and interact. Pathophysiological methods like airflow obstruction and abnormal lung compliance impact breathing patterns to some extent, however, these breathing patterns can be altered by focused attention or training to influence the usage of inspiratory and expiratory muscles.

Postural modification, breathing control, pursed lips breathing, and 'blow as you go' are among the few physiotherapy techniques used to help COPD patients manage their breathlessness. These enhance respiratory muscles, and airway mechanics, allowing for a reduction in operating lung volumes by extending expiratory time. Singing may even improve sputum clearance by increasing dynamic lung volume and airflow, both of which are parts of traditional physiotherapy techniques.

Can singing be an Intervention for COPD and asthma?

Singing has received research attention as a treatment for asthma and COPD, possibly due to its promise of increased well-being in healthy people. More importantly, the breathing control used in formal singing training can be similar to that of COPD and asthma controlled breathing instruction.

People with asthma frequently have poor symptom control and seek non-pharmacological treatment, such as breathing exercises, to help them manage their disease. Encouraging slow exhalation and involving the abdomen or diaphragm rather than the chest is frequently recommended as an adjunctive treatment for asthma, particularly in those who have not improved with pharmacological treatment. One study found that 15 minutes of diaphragmatic breathing resulted in increased breathlessness, whereas another study found that diaphragmatic breathing training for four weeks has improved both breathlessness and quality of life.

COPD

An intervention study with controlled training was conducted by Engen et al. in 2005 with 7 participants of various degrees of COPD (average age of 72) for six weeks. The study included singing combined with breathing warm-up (slow expiration) and vocal exercises (using abdominal muscles to support the voice).

Results showed that participants shifted to the training predominantly diaphragmatic mode of breathing, from primary chest mode of breathing. Furthermore, breathing support (speech intensity) and single breath counting (counting for a longer period without taking a new breath) improved throughout the study. However, walking distance and forced expiratory volume in the first second (FEV1) did not improve.

Another study with uncontrolled training was conducted by Morrison et al. with 106 participants of various degrees of COPD for 10 months. In this study, breathing exercises were a part of the singing intervention.

The results showed significant improvements in FEV1% and FVC% (values expressed as a percentage of expected values), along with total and impact subscales of respiratory quality of life between the start and end of the study. However, there were no improvements in measures of breathlessness or overall quality of life.

Asthma

One study examined singing in people with asthma. Given that most asthma singing research is conducted on children, this project served as a preliminary study of singing for adults with asthma. In the first study, 93 young students (M = 19.4, SD = 1.53) with self-reported, primarily mild (n = 62) asthma completed a survey about participation in and perception (as asthma-helpful) of activities that included singing. Most participants (98%) reported exercising or playing sports, and 65% reported singing. Using McNemar's test p <0.001, those who reported participating in both singing and exercising (n = 54) endorsed exercise (85%) over singing (34%) as helping control their asthma.

Conclusion

Singing for respiratory health is still promising but indecisive at this point. This concurs with past conclusions in published reviews on singing for health and well-being. Several studies do not show improvements in respiratory health but rather in the quality of life or well-being, which have a significant immediate impact and may have a long-term effect on respiratory health.

Although preliminary research has been encouraging, larger-scale and long-term studies are required to demonstrate the efficacy of this intervention before it can be recommended in clinical guidelines.

References:

• Gick, M. L., & Nicol, J. J. (2015). Singing for respiratory health: theory, evidence and challenges. Health Promotion International, 31(3), 725-734.
• Lewis, A., Cave, P., Stern, M., Welch, L., Taylor, K., Russell, J., … & Hopkinson, N. S. (2016). Singing for Lung Health—a systematic review of the literature and consensus statement. NPJ primary care respiratory medicine, 26(1), 1-8.
• Philip, K., A. Lewis, and S. Harrison. Singing and dance for people with chronic breathlessness during the COVID-19 pandemic: American thoracic Society, 2020.

Further Reading

• All Lung Capacity Content
• Lung Plethysmography Procedure

Written by

Aimee Molineux

Aimee graduated from Oxford University with an undergraduate degree in Japanese and Korean Studies, with an exchange year at Kobe University in Hyogo, Japan. Throughout her studies, Aimee took part in various internships, gaining an interest in marketing and editorial work along the way.In her personal time, Aimee can be found either attempting to cook, learning how to code, doing pilates, as well as regularly updating her pet hamster’s Instagram account.