SingStrong – singing for better lung health in pulmonary fibrosis: A feasibility study

Abstract

BACKGROUND & PURPOSE:

Pulmonary fibrosis (PF) is a debilitating, incurable disease. Strategies to optimise health-related quality of life and minimise symptom impact are advocated. Available treatment options such as pulmonary rehabilitation have been severely disrupted due to COVID-19. This feasibility study explored the clinical efficacy and acceptability of an online singing and breathing retraining programme (SingStrong) for people with PF.

METHODS:

The weekly online programme conducted over 12 weeks was comprised of 45-minute classes of mindfulness, breathing retraining, vocal exercises and singing conducted by a trained vocal coach. People with PF were invited to participate and sessions were recorded for non-attenders. Demographic data were collected, and the St Georges Respiratory Questionnaire (SGRQ) and Idiopathic PF Patient Reported Outcome measure (IPF-PROM) were administered. The questionnaire also invited participants to provide feedback on the utility, enjoyability and main pros/cons of the intervention. Participation in the research element of the programme was not required to attend the weekly classes.

RESULTS:

Of 24 participants recruited, data from 15 (mean (Standard Deviation) age of 66 (8.7); male: n = 8) who completed both pre and post-intervention questionnaires were analysed. Statistically significant improvements were recorded in the IPF-PROM (p = 0.019) and self-reported quality of life (p = 0.028). Class attendance by study participants and the broader PF group cumulatively, increased from 14 to 25 participants between weeks 1 and 12. Qualitatively, strong satisfaction with classes and improved efficacy in self-management of lung health, in particular breathlessness, were reported.

CONCLUSIONS:

Singing and breathing retraining interventions may endow biopsychosocial benefits for people with PF, in the presence of modest objective clinical gains. Singing programmes are popular and may provide helpful adjuncts to existing clinical strategies such as pulmonary rehabilitation.

Keywords

Pulmonary Fibrosis Singing for lung health Online rehabilitation SingStrong

1 Introduction

Pulmonary fibrosis (PF) is a chronic, progressive and typically life-limiting disease characterised by scarring and stiffening of the lung parenchyma, reduced capacity for gaseous exchange and marked respiratory compromise for the patient [1]. Of the main two types of PF –familial and idiopathic pulmonary fibrosis (IPF)- the latter is more common, with a life expectancy of between three and five years post diagnosis [1]. PF currently affects up to three million people globally, with numbers on the increase [2]. There is a marked incidence of serious co-morbidity with PF including pulmonary emphysema, gastroesophageal reflux, lung cancer, pulmonary hypertension and sleep disorders, in addition to the acute exacerbation of the underlying condition [3]. The mechanism of the aberrant fibrosis in PF remains unclear, with proffered theories including repeated micro-injury to a genetically predisposed alveolar epithelium, followed by an abnormal healing response hallmarked by excessive collagen deposition [4]. There is no cure for PF, with current pharmaceutical management capable only of slowing functional decline and disease progression [4]. With the lack of curative therapies, strategies to optimise quality of life (QoL) and the biopsychosocial wellbeing of this population must be a priority.

Breathlessness, cough, reduced exercise endurance, fatigue, anxiety, depression and weight loss are among the most common problems faced by this population [5].The impact of the COVID-19 pandemic has further complicated the management of these symptoms. The risk factors for poor outcomes in COVID-19 are common in people with PF, who already have compromised pulmonary reserves. It is probable that the prognosis for PF patients with COVID-19 is more ominous than for the general population, or cohorts with other chronic conditions [2]. Furthermore, the requirement for people with PF to limit their social interactions and cocoon due to their health status, is likely to also have marked adverse effects on their mental as well as physical health [6].

Robust evidence supports pulmonary rehabilitation (PR) as a preferred conservative strategy to address the challenges faced by people with PF [7], and early access to a bespoke PR programme is advocated in the Irish Thoracic Society’s position statement on the management of PF [8]. However, the curtailment of in-person PR classes has adversely impacted this important pillar of care for this population, even as many service providers attempt to move classes online. There are currently mixed results on the feasibility and acceptability of virtual PR classes, with available studies being of small cohort sizes and of variable methodological quality [9, 10]. In addition, many of these studies involve patients with Chronic Obstructive Pulmonary Disease (COPD), with results that may or may not be generalisable to PF patients with restrictive breathing patterns. Even in pre-pandemic times, availability of, and compliance with PR was historically low in Ireland with many patients unwilling or unable to engage with services when offered [11]. Therefore alternative approaches that address the biopsychosocial issues associated with PF, while embodying tenets of exercise and education inherent in PR, are worthy of investigation.

Singing interventions in lung pathologies aim to improve the efficiency of respiration through optimal recruitment of the primary muscles of respiration, while simultaneously enhancing QoL and ameliorating psychological distress [12]. A systematic review exploring the benefits of singing for lung health found that such interventions have the potential to improve bio-psychological health-related (HR) QoL, without incurring significant side effects [13]. In patients with PF, impaired gas exchange has been identified as the primary cause of exercise intolerance, with associated extra-pulmonary consequences including reduced health-related QoL, fatigue, and/or anxiety and depression [14]. Community based programmes that use singing and breathing control to address these respiratory and broader QoL issues have been successfully delivered to cohorts with COPD [15], with recent evidence from the United Kingdom reporting benefits from online classes including a reduction in depression and greater balance confidence in a COPD cohort [16]. However, it is unclear if such an online intervention would be feasible in a PF population, who typically have more complex presentations and poorer prognoses than patients with COPD. This feasibility study therefore aimed to evaluate the clinical efficacy and acceptability of an online group singing and breathing programme (SingStrong for Lung Fibrosis) for people with PF.

2 Methods

This project was conducted in partnership with the Irish Lung Fibrosis Association (ILFA), the national patient organisation for lung fibrosis in the Republic of Ireland. Founded in 2002, ILFA support patients and families living with PF. The 12-week SingStrong programme (including one bank holiday with no class) ran over the summer of 2021 and was delivered online via Zoom^TM due to the ongoing COVID-19 pandemic. SingStrong was established in 2018 by authors RC and CM, who have successfully delivered similar classes to people with COPD, those with Long COVID and chronic lung conditions in both in-person and online settings [15].

2.1 Participants

A sample size calculation was not performed for this study which used a sample of convenience. However a similar in-person study of a 12-week singing and breathing retraining programme in patients with Idiopathic Interstitial Pneumonias (IIP) recruited just ten participants [17]. A convenience sample of members of ILFA, including patients and family members were invited to attend an information session led by the Principal Investigator (RC) who is an experienced respiratory physiotherapist; and the vocal coach (CM), who is a trained singer and experienced community musician. Thirty patients plus additional family members attended the online meeting, which provided information on the rationale for the project, details of the class, and allowed time for queries. Of this number, twenty-four patient attendees agreed to participate in the trial. There was no requirement for people to participate in the research element in order to access the SingStrong intervention. Participants were required to be 18 years or older with a clinical diagnosis of PF (including both familial and IPF). Access to the internet and a suitable device (laptop, tablet etc.) were also required to participate in the intervention.

2.2 Intervention

The 45-minute online classes over 12 weeks consisted of a brief seated five-minute physical warm-up, followed by approximately 20 minutes of vocal and breathing exercises to encourage appropriate diaphragmatic and intercostal muscle recruitment, and concluded with a 20 minute period of singing. Songs were chosen in collaboration with the participants, and informed by likely disease-related limitations of breathlessness and work of breathing. Participants were encouraged to go at their own pace and their sound was muted for the majority of the class due to broadband synchronicity issues. Classes were video recorded and made available to participants afterwards, to facilitate additional practise during the week, which was encouraged, and/or to allow people to catch up if they had missed a class. Optional online breakout rooms were offered to participants to allow them to connect with other members after the class. These breakout sessions were not monitored or recorded.

2.3 Outcome measures

Data were collecting via a 30-minute online questionnaire. Demographic data (age, sex, medical history, employment details) were collected. The St Georges Respiratory Questionnaire (SGRQ) [18] and a bespoke IPF Patient Reported Outcome measure (IPF-PROM) [19] also formed part of the questionnaire. The SGRQ is a 50-item questionnaire comprised of three domains: symptoms (severity and frequency), activity (effects of breathlessness on physical activity), and impact (psychosocial impact of the condition) [20]. Scores of domains and overall score range from zero to 100, with higher scores indicating an inferior HRQoL [20]. It has been widely used to assess disease impact in people with PF, as well as a prognostic tool for mortality in this cohort [21]. The IPF-PROM was developed in line with Food and Drug Administration guidance on patient-reported outcome measure development, and involved approximately 600 participants recruited through United Kingdom and Irish PF charities [22]. It is a 12-item tool that asks respondents about the impact of their disease on their biopsychosocial wellbeing over the previous two weeks. Items are scored from 1–4, with higher scores indicating a poorer HRQoL. The highest possible score for the tool is 48. Additional questions pertaining to cough, general health and overall HRQoL are scored separately. Likert scales from one to five were used to capture these domains with a higher score indicating better general health and HRQoL, but a worsening urge to cough. These questions, the SGRQ and the IPF-PROM were re-administered post intervention as were a number of questions pertaining to satisfaction with the intervention. Patients were asked to rate the efficacy of the programme in helping participants to manage their lung issues, and their enjoyment of the programme. Both of these parameters were rated one (worst) to five (best). Secondary outcome measures of recruitment, adherence and retention were also collected. The questionnaire also provided the opportunity for participants to provide comments on the three best facets of the programme as well as areas for improvement.

2.4 Statistical analysis

Descriptive statistics are reported using mean and standard deviation (SD) for normally distributed variables, median (interquartile range (IQR)) for non-normal variables, and percentages for categorical variables. The distributions of all numeric variables were assessed for skewedness using formal tests (Kolmogorov-Smirnov and Shapiro-Wilk [23]) and through visual inspection of histograms. Chi-squared tests were used to investigate association between categorical variables. Paired sample t-tests were used to evaluate pre-post data, with Student’s t-test (normal distribution) or Wilcoxan’s W (non-normal distribution) used as appropriate. Statistical significance was set at p < = 0.05. Statistical analysis was conducted using Jamovi^TM Version 2.2.5. Data provided on the three best facets and areas for improvement of the intervention was evaluated by reviewing the written text, and subsequently identifying and grouping common themes.

Ethical Approval for this project was provided by the ethics committee of the relevant faculty in the local University (2019_04_06_EHS).

3 Results

3.1 Participants

Thirty individuals attended the introductory meeting with the research team. Of these, 24 (80%) completed the pre-intervention questionnaire, but of these only 15 (55%) also completed the final post-intervention questionnaire. Eight males and seven females, with a mean (SD) age of 66 (8.7) years comprised this cohort of participants. Twelve (80%) participants were retired, with two (13.3%) not seeking work, and just one participant (6.6%) in full time employment. In addition to PF (IPF: n = 14; familial: n = 1), one participant each reported also suffering from co-morbid asthma, COPD, sarcoidosis and one patient was post lung-transplant due to PF.

3.2 Questionnaire-based outcome measures

The SGRQ pre-post analysis found small, statistically non-significant improvements in the total overall score (p = 0.926) as well as in the activity domain (p = 0.582). Non-significant deteriorations in the symptom (p = 0.837) and impact domains (p = 0.905) were also observed. There were no changes in any domain that exceeded the 11-point threshold for a minimal clinically important difference (MCID) in this population [24]. There was a statistically significant improvement in the scores for the IPF-PROM post intervention (p = 0.019), with participants also reporting small improvements in general well-being (p = 0.136), and in the urgency of coughing (p = 0.433), although these were both non-significant. There was a significant improvement in QoL reported post intervention (p = 0.028) (Table 1).

Table 1
Pre to post changes in St Georges Respiratory Questionnaire (domains and overall), IPF-PROM, urge to cough, general health and quality of life

Assessment Statistic p Mean diff. SE diff. Effect Size

St Georges Respiratory Questionnaire

Symptoms (Pre) Symptoms (Post) Student’s t 0.2095 0.837 2.572 12.28 Cohen’s d 0.0541

Wilcoxon W 55.0 0.900 3.34 12.28 Rank biserial correlation 0.0476

Activity (Pre) Activity (Post) Student’s t 0.5638 0.582 –6.717 11.92 Cohen’s d –0.1456

Wilcoxon W 49.0 0.561 –6.46 11.92 Rank biserial correlation –0.1833

Impact (Pre) Impact (Post) Student’s t 0.1218 0.905 0.976 8.01 Cohen’s d 0.0315

Wilcoxon W 62.0 0.934 1.50 8.01 Rank biserial correlation 0.0333

Total (Pre) Total (Post) Student’s t 0.0949 0.926 –0.887 9.35 Cohen’s d –0.0245

Wilcoxon W 58.0 0.934 –2.63 9.35 Rank biserial correlation –0.0333

IPF-PROM

IPF-PROM (Pre) IPF-PROM (Post) Student’s t 2.65 0.019^* 4.33 1.64 Cohen’s d 0.683

Wilcoxon W 99.0 0.028^* 5.00 1.64 Rank biserial correlation 0.650

Cough, wellbeing &quality of life

Urge to cough (Pre) Urge to cough (Post) Student’s t 0.807 0.433 –0.333 0.330 Cohen’s d 0.208

Wilcoxon W 13.50 0.590 –1.000 0.330 Rank biserial correlation 0.286

General wellbeing (Pre) General wellbeing (Post) Student’s t –1.581 0.136 0.267 0.211 Cohen’s d –0.408

Wilcoxon W 8.00 0.152 1.000 0.211 Rank biserial correlation –0.556

Quality of life (Pre) Quality of life (Post) Student’s t –2.45 0.028^* –0.400 0.163 Cohen’s d –0.632

Wilcoxon W 4.50 0.041^* –1.00 0.163 Rank biserial correlation –0.750

Assessment			Statistic	p	Mean diff.	SE diff.		Effect Size
Urge to cough (Pre)	Urge to cough (Post)	Student’s t	0.807	0.433	–0.333	0.330	Cohen’s d	0.208
		Wilcoxon W	13.50	0.590	–1.000	0.330	Rank biserial correlation	0.286
General wellbeing (Pre)	General wellbeing (Post)	Student’s t	–1.581	0.136	0.267	0.211	Cohen’s d	–0.408
		Wilcoxon W	8.00	0.152	1.000	0.211	Rank biserial correlation	–0.556
Quality of life (Pre)	Quality of life (Post)	Student’s t	–2.45	0.028^*	–0.400	0.163	Cohen’s d	–0.632
		Wilcoxon W	4.50	0.041^*	–1.00	0.163	Rank biserial correlation	–0.750

IPF-PROM: Idiopathic pulmonary fibrosis Patient Related Outcome Measure.

3.3 Efficacy and enjoyment

In terms of satisfaction with the SingStrong intervention, responses were favourable overall, with efficacy and enjoyment of the programme rated at 3.7/5 and 4.7 out of 5 respectively. When asked if they would avail of a similar programme again, 14 of the 15 (93%) participants said that they would. Data were not collected as to why participants would not choose to continue with a further programme.

The participants also provided numerous comments with regards to the positives and negatives of the programme. The main positive facets identified by the 15 participants included the breathing retraining exercises, relaxation exercises and the enthusiasm of the choir leader (CM). Numerous participants reported how much enjoyment they derived from the programme (Table 2).

Table 2
Strengths of the SingStrong programme according to participants

Participant What were the three best things about SingStrong?

1 Breathing exercises. Drinking straw session. Learning to sing.

2 Meeting on-line.

3 Learning about breathing discipline. Relaxation exercises. Exercises using drinking straw and glass of water.

4 Being part of a group activity that was positive and fun

5 I became more aware of the influence of stress in my vocal chords and throat area on my coughing and learned useful techniques to manage same and to control my breathing. Also learned the importance of using different areas of resonance and conserving oxygen and that practice will lead to an improvement.

6 Ciara, the teacher. Camaraderie. Great tips.

7 Ciara’s enthusiasm; Relaxation exercises; Breathing exercises - very beneficial.

8 Being taught how to breathe properly. The technique behind singing. How to relax the body.

9 Breathing exercises. Interaction with others. Personality of presenter

10 It teaches you how to breathe properly - use the different parts of your body to help you breathe and sing properly.

11 A fun way to help with managing lung issues, very useful exercises to maximise voice control and the positivity in the way the programme was conducted resulting in great group interaction with singing “exercises”.

12 Breathing exercises, fun to do, relaxation

13 Singing. Breathing control. Ciara.

14 Learning breathing exercises, control of breathing, enthusiastic teacher

15 Fun, improved my breathing and my control over my breathing

Participant	What were the three best things about SingStrong?
1	Breathing exercises. Drinking straw session. Learning to sing.
2	Meeting on-line.
3	Learning about breathing discipline. Relaxation exercises. Exercises using drinking straw and glass of water.
4	Being part of a group activity that was positive and fun
5	I became more aware of the influence of stress in my vocal chords and throat area on my coughing and learned useful techniques to manage same and to control my breathing. Also learned the importance of using different areas of resonance and conserving oxygen and that practice will lead to an improvement.
6	Ciara, the teacher. Camaraderie. Great tips.
7	Ciara’s enthusiasm; Relaxation exercises; Breathing exercises - very beneficial.
8	Being taught how to breathe properly. The technique behind singing. How to relax the body.
9	Breathing exercises. Interaction with others. Personality of presenter
10	It teaches you how to breathe properly - use the different parts of your body to help you breathe and sing properly.
11	A fun way to help with managing lung issues, very useful exercises to maximise voice control and the positivity in the way the programme was conducted resulting in great group interaction with singing “exercises”.
12	Breathing exercises, fun to do, relaxation
13	Singing. Breathing control. Ciara.
14	Learning breathing exercises, control of breathing, enthusiastic teacher
15	Fun, improved my breathing and my control over my breathing

Of the 15 participants, eight had no suggested improvements to make. Other comments which included extending the classes, the provision of practise programmes and more time for singing, are listed here (Table 3).

Table 3

Weaknesses/areas for improvement of the SingStrong programme according to participants

Participant	Can you suggest three areas where the SingStrong programme might be improved?
1	Learn a few more words of songs.
3	Slightly longer classes
4	Combining song and exercise from the start - I feel that if classes continued in a group format more likelihood for people to be consistent doing exercises on their own, people with severe IPF can find they are busy just managing to get up and ready and manage their condition. Ciara was such an enthusiastic facilitator and I really enjoyed the positive interaction with her and the group, you just don’t get that with a video.
5	A practice plan for a daily exercise programme, perhaps spanning a few weeks, would help to keep me on track and ensure that I cover all the useful skills learned during the course.
6	Easier group song that everyone could sing and words given in advance
8	More classes and more singing.
11	Maybe just have a bit more time on the programme for the group to sing. Otherwise I thought it was excellent.

3.4 Adherence and retention

In terms of adherence, the mean (standard deviation (SD)) attendance over the eleven sessions was 17.6 (4.2) participants per class, ranging from 14 to 25 attendees per class. Interestingly, attendance increased over the period of the study from 14 or 15 participants in the first four weeks to 25 participants in the last two weeks of the study. Of the 15 participants who completed the pre and post questionnaires, mean (SD) attendance was 7.7(2.5) classes from a possible eleven classes in total. Details of number of participants accessing recordings were not collected. Reasons for non-attendance were not formally recorded although the ILFA gatekeeper anecdotally reported reasons including illness and clashing healthcare appointments.

4 Discussion

PF is a progressive, debilitating and typically fatal disease that affects every facet of the patient’s life and wellbeing. Interventions that address the biopsychosocial wellness and QoL of the patient are advocated. The ongoing COVID-19 pandemic has proved challenging for the PF community who are vulnerable to adverse outcomes from the virus, and for whom social isolation associated with government guidance to cocoon has become the norm. Online interventions offer access to treatment options for this cohort, although the efficacy of this is not clear. This study examined the clinical efficacy and acceptability of an online singing and breathing retraining programme (SingStrong) for a PF population of convenience in Ireland. Results indicate some modest clinical gains, with high attendance rates reflecting participant enjoyment and perceived benefits in managing their lung health.

A key fundamental underpinning the efficacy of singing for better lung health is the utilisation of the cardiorespiratory system during persistent singing training, resulting in enhanced respiratory muscles and an optimized breathing mode [12]. Breathing pattern retraining has shown to improve multiple physiological outcomes for COPD patients [25], but there is a paucity of evidence in this area in PF. The impact of the SingStrong programme on respiratory and other common symptoms in this study was evaluated using self-complete questionnaires and showed variable results. The symptom and impact domains of the SGRQ showed small non-significant deteriorations, with the activity domain and overall total score showing small improvements although these were not statistically significant. In contrast to a ten-week singing intervention in COPD involving participants with comparable SGRQ baseline scores to the current study, statistically significant improvements were noted in all scores except the activity domain, which also improved slightly [26]. The comparative capacity for clinical improvement in COPD and PF may be limited however, given the underlying physiology of both conditions and the greater severity of PF. In addition, in the current study there were no clinically meaningful changes that met the criteria for PF using the SGRQ. In contrast to COPD where the MCID is just four points, a recent update on the issue noted a much higher MCID of 11 points in PF [24]. However that study notes that “real-world” PF MCID values are likely to be variable and dependent upon factors such as disease severity.

The IPF-PROM questionnaire in contrast showed significant improvements in outcomes for participants with a medium effect size (> 0.6). This is likely due to the bespoke nature of the outcome measure, which addresses issues more particular to PF, in contrast to the more generic nature of the SGRQ. The main domains of the IPF-PROM relate to physical and affective breathlessness, emotional wellbeing and fatigue [22], in comparison to the strong functional focus of the SGRQ. Given the emphasis of the SingStrong intervention on breathlessness and holistic wellbeing, the positive outcome using the IPF-PROM questionnaire is unsurprising. It is also arguably a better reflection of the participant experience of the intervention.

This study also found positive results regarding self-reported QoL, general well-being and urge to cough. Similar results were reported in a small 12-week study of ten participants with IIP [17]. The study by Russell et al. reported self-reported improvements in physical, psychological well-being, cognitive and social functioning, although spirometry measures were unchanged. Research indicates that after dyspnoea, extra-pulmonary problems such as poor HRQoL, depression and anxiety are the most distressing disease manifestations for patients with PF [14]. Singing interventions have previously been found to be effective in addressing several of these issues in cohorts with chronic respiratory cohorts, in particular COPD [15 , 27–29]. In a 2010 study of singing in chronic respiratory conditions by Lord and colleagues [28], COPD patient participants reported benefits in numerous domains including physical sensation, general well-being, community/social support and achievement/efficacy. Over 80% of respondents also reported “a marked physical difference” due to the singing intervention. Notably, this was in the absence of any improvement in several objective parameters including single breath counting, breath hold time or shuttle walk distance. Similarly in a post-lung cancer cohort, improvements in several QoL domains, depression, anxiety, confidence and self-esteem were recorded in the absence of any positive change in lung function, respiratory muscle strength or fatigue [30]. It would therefore appear that singing interventions such as that in the current study may provide meaningful, life-enhancing gains even in the absence of objective clinical change. Proposed mechanisms for this include chemical changes such as upregulation of oxytocin, immunoglobulin A, and endorphins, which improves immune function and increases feelings of happiness [31]. Alternative hypotheses purport that benefits may be derived from engagement in an enjoyable activity with individuals dealing with the same challenges, thus creating a community of support and understanding [30]. This theory is supported by the level of enjoyment noted by participants in this study, who also reported good overall programme efficacy in helping them managing their lung health.

Rates of attendance and adherence to the programme were also encouraging. Class attendance trended upwards from the initial one or two weeks, with number of class attendees increasing by approximately 180% from week 1 to week 12. The reasons for this are unknown but word of mouth is likely to have contributed given that participants were recruited from a single source (ILFA). The growth in attendance also reflects the exceptionally high levels of enjoyment reported by the participants in the SingStrong programme, and their enthusiasm for additional future programmes. This is further supported by the qualitative feedback provided by the participants. On the whole, this was largely positive and reflects perceived benefits in their mastery of breathlessness and relaxation techniques. Several participants also alluded to the fun and friendly atmosphere created in the class as well as the sense of community and support derived therein. Popularity of singing for lung health problems has been consistently reported in the literature [32, 33], in contrast to PR where rates of adherence and retention are poor on the whole [34]. Although not explicitly evaluated, these findings also support satisfaction with an online environment that is comparable to in-person attendance reported at previous in-person SingStrong programmes for participants with COPD [15].

5 Limitations

This was a small population of convenience drawn from one source, and findings may not be generalizable to other settings. A sample size calculation should have been performed in advance of the study to add rigour. In particular, the strong positive influence of the vocal coach may skew results and may not be replicable elsewhere. Due to the pandemic, it was not possible to obtain objective clinical measures such as spirometry, which may have added to the study. The severity of disease was not established and may have had a bearing on the ability of the participants to participate in the intervention. Finally, although volunteers were sought for a follow-up focus group, only three participants stepped forward. The authors agreed that this would not provide a balanced and diverse pool of feedback and as such have not included those findings in this script. The addition of such qualitative data would have greatly enhanced any insights into the strengths and weaknesses of the programme in this particular cohort. A related issue is the limited capacity of the interpretation of the inferential tests applied in this study, which do not reflect the typical primary aims of feasibility studies.

6 Conclusion

Singing for better lung health offers a viable treatment adjunct for people with PF. Given the prognosis and available treatments for PF, it is debatable whether significant objective clinical improvements are achievable in these patients, or whether maintenance of current health status should be the aim. The importance of more holistic factors such as self-efficacy, HRQoL and positive mental health may therefore assume a greater priority. Programmes such as “SingStrong” which offer an enjoyable, community-based intervention, in addition to targeted breathing retraining, appear to be acceptable in an online setting, and are capable of engendering positive perceived changes to health and HRQoL.

Footnotes

Acknowledgments

The authors would like to thank all the study participants and the Irish Lung Fibrosis Association for their support.

Conflict of interest

The authors have no conflict of interest to report.

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