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. 2026 May 6;2026(5):CD016265. doi: 10.1002/14651858.CD016265

Singing for adults with chronic respiratory disease

Mette Kaasgaard 1,2,✉, Stephen Clift 3,4, Camilla Hansen Nejstgaard 5,6, Kirsten Buch Rasmussen 7, Katarzyna Grebosz-Haring 8,9, Helene Louise Hartmeyer 1,2, Morten Hostrup 10, Arne Bathke 11,12, J Matt McCrary 13,14
Editor: Cochrane Central Editorial Service
PMCID: PMC13147495  PMID: 42089381

Objectives

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To evaluate the benefits and harms of singing for chronic respiratory diseases in adults compared to all studied comparison groups.

Background

Description of the condition

Chronic respiratory diseases are heterogeneous and irreversible, and include chronic obstructive pulmonary disease (COPD), asthma, interstitial lung diseases (ILD), sarcoidosis, pneumoconiosis, cystic fibrosis, and lung cancer [1, 2, 3]. The prevalence of chronic respiratory diseases is rising. COPD currently affects around 10% to 12% of the global population, and asthma around 7% to 10% [4, 5]. Chronic respiratory diseases represent the third leading cause of deaths worldwide [1, 2], and are associated with a profound burden and cost [2, 6]. The main risk factors for the development of chronic respiratory diseases are tobacco smoking, environmental or occupational exposures (e.g. pollution, chemicals, and dust), frequent respiratory infections during childhood, and genetic factors [1, 2].

Chronic respiratory diseases cause functional and structural changes in the airway system, leading to impaired respiratory, pulmonary, and circulatory function [7, 8, 9, 10]. Common symptoms include coughing, sputum, dyspnoea, and impaired health‐related quality of life (HRQoL) [11]. A key pathophysiological feature is impaired strength and co‐ordination of the respiratory muscles, particularly of the diaphragm [12, 13], leading to reduced airway clearance, impaired oxygenation and carbon dioxide washout, and limited ability to perform physical exercise [14, 15]. Chronic respiratory diseases are also frequently associated with a sedentary lifestyle, resulting in a self‐perpetuating cycle with increased symptoms, impaired HRQoL, and increased risk of deconditioning and early mortality [16, 17, 18]. To manage chronic respiratory diseases and increase health status, prognosis, and survival, treatments, such as pharmacological interventions are essential, along with risk modification interventions, potential surgical procedures, or both [19, 20, 21]. In addition, support for appropriate lifestyle changes is a key component in comprehensive care [6, 22, 23].

Description of the intervention and how it might work

Pulmonary rehabilitation is a well‐evidenced, well‐established, and cost‐effective non‐pharmacological intervention, and is recommended by both the European Respiratory Society (ERS) and the American Thoracic Society (ATS) [23, 24]. Pulmonary rehabilitation primarily aims to improve exercise capacity, HRQoL, and symptoms, and to support lifestyle changes, self‐management, and disease‐control. Pulmonary rehabilitation is a multidisciplinary intervention, which includes smoking cessation, patient‐centred education on disease‐management, and physical activity [6, 22, 25]. However, pulmonary rehabilitation with physical activity is challenged by low attendance and high drop‐out rates, due to many reasons, including lack of availability and awareness, low patient motivation and an inability to perform physical activity [22, 26, 27, 28]. Poor compliance with continued physical activity following pulmonary rehabilitation is well‐known [23, 27, 28, 29, 30]. Accordingly, there have been multiple calls for investigations of novel, relevant, and motivating interventions as supplements or alternatives to physical activity, with a view towards a future evidence‐based pulmonary rehabilitation model that is increasingly personalised [6, 22].

Singing is a complex and embodied art form, intimately connected to posture, stamina, and breathing. The link between singing and chronic respiratory disease seems intuitive, and indeed, singing has become increasingly popular worldwide, both as a leisure activity and as a structured intervention within healthcare settings [31, 32, 33, 34, 35]. Studies have also suggested that singing benefits both psychosocial and physiological parameters [36, 37, 38, 39, 40, 41, 42], and offers an enjoyable and motivating alternative for those unable or unwilling to participate in physical activity within conventional pulmonary rehabilitation [41, 43, 44].

Specifically, studies have reported that singing improves HRQoL, reduces symptoms of anxiety and depression in chronic respiratory diseases [31, 37, 38, 45, 46, 47, 48], builds joy and social cohesion, and may foster long‐term attendance [32, 33, 34, 49, 50, 51].

The general advantages of singing are hypothesised to be associated with physiological factors [36, 51]. Overall, gaining control over the respiratory muscles is required to support vocal function and musical expression [32, 34, 36, 41, 43, 45], and is achieved through a complex interplay of the abdominal, intercostal, and upper respiratory muscles, alongside intermittent diaphragmatic co‐activation [52, 53, 54, 55]. Moreover, singing requires larger lung volumes and increased subglottal pressure compared to normal speech [56].

Specific physiological mechanisms of action during singing may include improved posture and stamina, along with a mechanically optimised position of the diaphragm to regulate air flow and pressure [57, 58, 59]. Singing is also associated with improved respiratory co‐ordination and dyspnoea control [36, 58, 60]. In general, techniques emphasising slow and controlled exhalation may reduce lung hyperinflation and air‐trapping, and improve breathing comfort [57, 58, 59]. These aspects may enhance apnoea tolerance and exercise capacity [34, 36], which suggests that singing confers physiologically‐oriented training effects [34, 36, 43, 50]. A randomised controlled trial (RCT), conducted within community‐based pulmonary rehabilitation for COPD, recently reported non‐inferiority of singing versus physical activity for functional capacity and HRQoL, related to a dose‐response pattern [43, 61]. However, it remains unclear whether singing provides clinically relevant adaptations, e.g. in respiratory muscle strength and function, and whether these adaptations translate into broader systemic, functional, and subjective benefits, including (but not limited to) key pulmonary rehabilitation outcomes [6, 22, 23, 24, 62, 63].

Why it is important to do this review

The prevalence of chronic respiratory diseases is rapidly increasing worldwide, and is a significant contributor to the global burden of disease, with COPD and trachea/bronchus/lung cancers consistently amongst the top 10 annual causes of global deaths (WHO Global Health Observatory, 2000‐2021) [64].

Physical exercise training‐based interventions within pulmonary rehabilitation have well established efficacy, but are limited by low uptake and retention, necessitating new intervention strategies to more effectively manage this global disease burden [22, 26, 27, 28]. In contrast, music‐based therapies, including (but not limited to) singing, are linked to increased motivation and high adherence in participants [65], although the mechanisms and magnitude of suggested clinical benefits are yet to be rigorously established [66, 67].

Three prior Cochrane reviews explored the effects of singing as an intervention for specific chronic respiratory diseases in both adults and children, specifically COPD [47], bronchiectasis [68], and cystic fibrosis [69], but all included very few studies. Since these reviews, further studies have been published, e.g. [70, 71, 72, 73], along with a variety of singing‐specific reviews for chronic respiratory diseases (most often, COPD), e.g. [74, 75]. The proposed effects of singing have also been described in several broader reports, e.g. [76], albeit marked by severe methodological limitations [77]. All of these examples reflect a growing public and scientific interest. Therefore, there is a need to conduct a new Cochrane review, based on a larger body of studies and including a range of chronic respiratory diseases for which singing has similar proposed mechanisms [34, 36]. This will highlight the current evidence and knowledge gaps, outlining a strategy for future research to further investigate efficacy, effectiveness, and underlying mechanisms of singing, for chronic respiratory diseases. This review may also elucidate the potential relevance and role of singing within increasingly personalised pulmonary rehabilitation programmes.

Objectives

To evaluate the benefits and harms of singing for chronic respiratory diseases in adults compared to all studied comparison groups.

Methods

Throughout, we will adhere to the Cochrane Handbook for Systematic Reviews of Interventions [78]. Specifically, we will follow the Methodological Expectations for Cochrane Intervention Reviews (MECIR) when conducting the review [79, 80], and the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA 2020; PRISMA‐S 2025) guidelines for the reporting [81, 82].

Criteria for considering studies for this review

To assess the effects of singing interventions for adults with chronic respiratory diseases, we will use the following PICO criteria:

Participants: adults with any chronic respiratory disease;

Intervention: singing; or singing as the main part of a multi‐modal intervention;

Comparator: all control groups;

Outcomes: Critical: health‐related quality of life (HRQoL), dyspnoea/breathlessness, functional exercise capacity. Important: pulmonary function, respiratory muscle strength/function, symptoms of anxiety, symptoms of depression, adverse events.

Types of studies

We will include studies with a randomised controlled trial (RCT) design, including cluster designs.

Types of participants

We will include all participants with chronic respiratory disease, who are aged 18 years and older, of either sex, and at any stage or severity of their disease. We will also include studies with mixed populations (i.e. studies of participants older and younger than 18, and studies with participants with different chronic respiratory diseases or with other additional diseases). If only a subset of participant data is eligible, or if data are not reported separately, we will contact study authors to request the relevant data. We will contact the corresponding author by email. If we are unable to obtain the requested study data (e.g. if there is no response from authors after two follow‐up contact attempts after the initial request), we will exclude the study.

Types of interventions

Intervention

We will include studies that include singing as the primary therapeutic intervention or component. In these interventions, singing may be accompanied by other components, such as breathing exercises or physical movement. In studies investigating music therapy with multiple components, we will only include studies with singing as the main intervention or component. The singing interventions may involve group singing (choir) or individual singing lessons.

All settings for the intervention are eligible for inclusion, e.g. research or health‐care facilities, community‐based, and online delivery (i.e. either face‐to‐face or online).

We will include studies of at least a four‐week duration (with no limitations on frequency or duration of sessions), so that we can evaluate pre‐post changes in a reasonable and conservative manner.

Comparator

We will include all active and passive comparator groups. Our initial pilot search showed that the control groups are heterogeneous and include active comparators (e.g. handcrafting, breathing exercises, physical exercise training) and passive comparators (i.e. usual care or no intervention).

Outcome measures

Following the defined outcomes in the Core Outcome Sets (COS) for pulmonary rehabilitation [62, 63], and outcomes used in the previous Cochrane reviews [47, 68, 69], we will investigate the following outcomes:

Critical outcomes

  1. Health‐related quality of life (examples of generic or respiratory‐specific measures, prioritised in the following order: 1) St. George’s Respiratory Questionnaire (SGRQ) [83, 84]; 2) 36‐item Short form survey (SF‐36) [85]; 3) COPD assessment test (CAT) [86]; 4) EuroQol questionnaires (EQ‐5D‐5L; EQ‐5D‐3) [87]).

  2. Dyspnoea/breathlessness (participant‐reported), any measures (examples of measures, prioritised in the following order: 1) Medical Health Research Council dyspnoea scale (MRC) or Modified Medical Health Research Council dyspnoea scale (mMRC) [88]; 2) Dyspnoea Visual Analogue Scale (VAS)) [89, 90].

  3. Functional exercise capacity (examples of disease‐specific measures, prioritised in the following order: 1) Six‐minute walk test (6MWT) [23, 25, 91, 92]; 2) Incremental shuttle walk test (ISWT)) [23, 91, 93].

Important outcomes

  1. Pulmonary function (examples of measures, prioritised in the following order: 1) forced expiratory volume in one second (FEV1, L/sec, % of predicted); 2) forced vital capacity (FVC, L, % of predicted); 3) FEV1/FVC ratio; 4) diffusion of carbon oxide (DLCO); 5) total lung capacity (TLC); 6) residual capacity (RC); 7) functional residual capacity (FCR) [22, 94, 95]).

  2. Respiratory muscle strength (examples of measures, prioritised in the following order: 1) maximal inspiratory pressure (MIP, PImax); 2) maximal expiratory pressure (MEP, PEmax) [14, 96, 97]).

  3. Symptoms of anxiety (examples of measures, prioritised in the following order: 1) Hospital Anxiety and Depression Scale (HADS) [98]; 2) General Anxiety Disorder‐7 Scale (GAD‐7) [99, 100]).

  4. Symptoms of depression (examples of measures: 1) Hospital Anxiety and Depression Scale (HADS) [98]).

  5. Adverse events/side effects (as defined by study authors).

We plan to only use validated questionnaires and assessment measures. If other relevant outcome measures are used for the critical and important outcomes, the authorship team will also consider them.

The critical outcomes are relevant to patients (consumers), clinicians, administrators, and policymakers. The important outcomes are clinically relevant and may be impacted by a singing intervention.

All outcomes will be reviewed at baseline and immediately after the end of the intervention. If there are additional long‐term follow‐up data, we will also review outcomes at the reported time points for follow‐up.

In case of missing data (e.g. if data regarding an outcome are not reported, if only per protocol data are provided, or if clarification is required), we will contact the study authors to request the relevant data. We will contact the corresponding author by email, and send up to two reminders.

When available, we will consider defined baseline cutoffs or thresholds for impaired status, defined minimal clinically important difference (MCID) or minimal important difference (MID) for change status, and whether the proportion of study participants who reached the cutoffs, thresholds, and MCID/MID were reported.

Outcomes of interest will not constitute an inclusion criterion for studies.

Search methods for identification of studies

Electronic searches

We explored the search strategy in the previous Cochrane reviews on singing [47, 68, 69], and identified the following electronic databases, which we will use to search for primary studies from inception until search date:

  1. Cochrane Central Register of Controlled Trials (CENTRAL; latest issue), in the Cochrane Library (crso.cochrane.org);

  2. Embase Ovid SP (1974 until search date);

  3. MEDLINE Ovid SP (1946 until search date);

  4. PsycINFO Ovid SP (1967 until search date);

  5. CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 until search date);

  6. AMED EBSCO (Allied and Complementary Medicine; 1995 until search date);

  7. Web of Science Core Collection (1900 until search date).

We will examine included studies for retraction statements by searching for retraction notices and retracted publications in MEDLINE Ovid, Embase Ovid, and Retraction Watch database (http://retractionwatch.org), and report the date this was done.

We will search the following registries for registered, ongoing, completed, and non‐published studies:

  1. ClinicalTrials.gov (www.clinicaltrials.gov);

  2. The World Health Organization International Clinical Trials Registry Platform (WHO ICTRP; www.who.int/clinical‐trials‐registry‐platform);

  3. The EU Clinical Trials Register (EUCTR; https://euclinicaltrials.eu/search-clinical-trials-reports).

For non‐published studies, we will contact study authors for registration and current status, and for potential retrieval of relevant data. We will contact the corresponding author by email, and send up to two reminders. If we do not receive a response, we will log unpublished studies to enable assessment of publication bias.

We will not restrict our search by publication date, language, or format.

Searching other resources

We will include these supplementary search strategies:

  1. Backward and forward citation search of all included studies;

  2. Full‐text searches in Google Scholar;

  3. Full‐text searches in Journal of Voice Ovid SP (1987);

  4. Handsearch proceedings from major respiratory conferences (e.g. the American Thoracic Society (ATS) International Conference (2001 onwards) and the European Respiratory Society (ERS) Congress (1992, 1994, 2000 onwards));

  5. Handsearch (using the Google search engine) for reports, dissertations, and theses;

  6. Contact leading researchers and experts in the field to ask about any ongoing trials or newly published results.

The preliminary search strategy and search terms were developed in collaboration with an information specialist (KBR) and are available in Appendix 1 (Supplementary material 1). The overall strategy will be peer reviewed prior to execution using the Peer Review of Electronic Search Strategies (PRESS) checklist [101].

Data collection and analysis

Selection of studies

Three review authors (MK, KR, KH) will independently screen titles and abstracts for obvious exclusions. We will manage search records using Covidence [102], and remove duplicates. We will perform a pilot assessment on at least two studies before initiating full‐text screening.

The same three review authors will independently screen the full texts for final inclusion according to the eligibility criteria. If we identify multiple reports from the same study, we will consider each report to be a unit of interest. However, multiple reports of the same study will be merged to avoid double counting. We will also report details of any unpublished studies or ongoing studies.

Discrepancies between the review authors will be resolved by discussion, or by using a fourth review author (MM) as arbiter. We will report the full selection process in a PRISMA flow chart, and report reasons for excluding the full‐text reports in a characteristics of excluded studies table.

The review authors will not perform any selection procedures of studies in which they were involved themselves. In these cases, the specific study will be handled by another review author for the study selection process.

Data extraction and management

We will extract the following information:

  1. Methods: study type, study design, country, study setting, total duration of study, duration of intervention, duration and frequency of sessions; sample size (number of participants included/completing), allocation/randomisation procedure, blinding of researchers/assessors, data collection procedure, analysis procedure, handling of missing data

  2. Participants: target group, disease(s) or condition(s), severity of disease, number of participants, age, sex, comorbidities, ethnicity, smoking status and history, lung function

  3. Setting: setting of study (hospital/community‐based/online/other)

  4. Interventions: rationale for singing, background of facilitators, training of singing leaders/teachers, content and delivery (e.g. structure of programme; components (breathing exercises, singing, warm‐up, movement, other components)), form of intervention (group/individual/online), setting of intervention (hospital/community‐based/online/other)

  5. Controls: rationale for the control, background of facilitators, content and delivery (e.g. structure of programme, form of intervention (group/individual/online))

  6. Outcomes: rationale behind study outcomes and measures, primary and secondary study outcomes (and measures) specified, outcomes and measures related to critical and important outcomes of the Cochrane review, data collection (e.g. procedure and person(s)), assessment time points reported, information on thresholds and on minimal important differences, analyses, handling of missing data

  7. Study report formalities: pre‐registration of study protocol, inclusion of a CONSORT flow diagram, inclusion of a statistician, a priori statistical power calculation, replication of previous study or not, stating of study limitations, information about trial funding, conflicts of interest of researchers/authors, reporting of adherence, drop‐out rate, and adverse events/side effects

Two review authors (MK, KH) will independently extract data from the included studies using a data extraction form, which will be piloted beforehand. A third review author (SC) will be consulted in case of discrepancies and no consensus. If data regarding an outcome are not reported, if only per protocol data are provided, or if there is insufficient reporting about, e.g. the intervention, we will contact study authors to request the relevant data. We will contact the corresponding author by email and send up to two reminders.

One review author (MK) will transfer data into Review Manager (RevMan) [103]. A second author (MM) will double‐check the overall data and specific in‐depth spot‐checks for the accuracy of the study characteristics against the included study reports.

The review authors will not extract or check any data from studies in which they have been involved themselves. In these cases, the specific study will be handled by another review author for the data extraction process.

Risk of bias assessment in included studies

Four review authors, in pairs (MK, SC, KH, MM), will independently assess risk of bias for all critical outcomes, according to the Cochrane Handbook for Systematic Reviews of Interventions [78].

We will use RoB 2 for RCTs (with variants for cluster‐randomised trials) to assess the included studies.

We will assess the following domains (and provide justification for our judgement):

  1. Bias arising from the randomisation process;

  2. Bias due to deviations from intended interventions;

  3. Bias due to missing outcome data;

  4. Bias in measurement of the outcome;

  5. Bias due to selective reporting.

Disagreements regarding risk of bias assessment will first be discussed amongst the four review authors involved in conducting risk of bias assessments. If they are unable to resolve the disagreement through discussion, a fifth review author (AB) will be asked to resolve the disagreement and make a final decision.

The risk of bias assessment will be reported in the Results section of the review, and will inform the subsequent assessment of the certainty of the evidence.

The effect of interest will be the effect of the assignment for all risk of bias assessments made using RoB 2.

Baseline confounding factors include, e.g. age, sex, and disease severity.

The primary review analysis will include data from all studies, without considering the risk of bias.

The review authors will not perform any risk of bias assessment for studies in which they have been involved themselves. In these cases, the risk of bias for the specific study will be assessed by another review author.

Measures of treatment effect

The nature of each outcome and study design will define the appropriate statistical analysis. Generally, the analysis will involve numerical and visual descriptive elements fitting to the outcome variables, as well as a quantification of uncertainty (i.e. confidence intervals for effect sizes), wherever possible.

The following analyses are preferred:

  1. Dichotomous data: mosaic plots, odds ratios (OR);

  2. Metric data: mean and median difference (MD) if the same scale is used, or standardised mean difference (SMD) if different scales are used. Additionally, we will calculate the widely applicable nonparametric relative effect (a.k.a. probabilistic index or Mann‐Whitney effect);

  3. Ordinal data: non‐parametric relative effect.

We will present findings with 95% confidence intervals (CI), wherever possible, and how they relate to the defined MCID or MID.

If multiple time points are included, we will only consider the change from baseline to the assessment point immediately after intervention termination (for continuous data).

For ease of comparison, and where relevant, we will ensure that data are entered with a consistent direction of effect, such that lower scores indicate improvement.

For studies performed before the adoption of this framework, for consistency reasons, we prefer intention‐to‐treat (ITT) data (or full analysis set) over completed or per protocol (PP) analyses.

Two review authors (AB and MM), who are statistical experts, will analyse the data using R software [104, 105].

Unit of analysis issues

The individual will be the primary unit of analysis for all RCTs that randomised individual participants. Appropriate methods for integrating cluster‐randomised trials will be determined based on risk of bias appraisals and analysis methods used in included studies. Appropriate methods include analyses conducted at the level of allocation, reduction of trials to their effective sample size using intracluster correlation coefficients, and inflations of standard errors that account for clustering [78]. We will combine multiple comparator groups included in multiple group studies to create a single pair‐wise comparison to address potential unit of analysis issues [78]; we do not anticipate studies that include multiple singing intervention groups.

We will assess the potentially significant impacts of cluster randomisation and multiple group studies on results through sensitivity analyses. We will define significant intercurrent events and handle them on a study by study basis, according to the estimand framework, according to the outcome(s) being potentially impacted, and as per previously described approaches [106].

Dealing with missing data

If there are missing data, studies available as an abstract only, or non‐published studies, we will contact study authors to request the relevant data. We will contact the corresponding author by email and send up to two reminders.

If there are missing data, we will also consider computing missing summary data from other relevant reported statistics.

If it is not possible to retrieve or compute data in a reasonable manner, and we consider this will cause serious bias, we will report the level of missing data and consider its effect on the certainty of the evidence for the affected outcomes.

Reporting bias assessment

We will assess the risk of reporting bias due to both selective reporting within included studies and the influence of publication bias on the cohort of included studies. We will evaluate selective reporting bias within the included studies through designated items in the RoB 2 assessments (see Risk of bias assessment in included studies). If we suspect a high risk of selective reporting bias, we will contact the corresponding author for clarification, missing data, or both. We will contact the corresponding author by email and send up to two reminders.

We will evaluate potential publication bias with graphical tools (e.g. funnel plots) for comparisons supported by 10 or more studies, as well as searches for unpublished studies (e.g. using clinical trial registries). Two review authors (MK and MM) will independently examine funnel plots to assess risk of publication bias; in case of disagreement, a third review author (AB) will be consulted.

The review authors will not perform any reporting bias assessment for studies in which they have been involved themselves. In these cases, the study will be assessed by another review author for reporting bias.

Synthesis methods

We will perform a meta‐analysis when it makes sense to statistically combine the data related to the critical and important outcome measures (e.g. more than three studies evaluating the same outcome measure in the same population). Meta‐analyses will analyse the effects of the intervention versus control groups (post‐intervention time point). Due to the diversity of settings, populations, singing interventions, and controls being considered, we anticipate that meta‐analysis using a random‐effects model will be most appropriate. Adjusted effect estimates (analyses that attempt to control for confounding) will be analysed, e.g. by the generic inverse‐variance (GIV) method, if appropriate. We will use the Restricted Maximum Likelihood (REML) estimator to estimate between‐trial variance. Alternatively, we will include other effect measures, such as odds ratios, as the basis for the meta‐analysis. We will use the Hartung‐Knapp‐Sidik‐Jonkman method to calculate a confidence interval for the meta‐analysis effect estimate when the estimate of heterogeneity is greater than zero. In other scenarios (i.e. where the estimate of heterogeneity is equal to zero), we will use the Wald‐type method.

If the data from some or none of the included studies are not suitable for a meta‐analysis, and if combining data across studies cannot be justified, we will display the results of the included studies in a forest plot, without the pooled estimate. We will sort studies in the forest plot by study design feature, or other relevant features. Alternatively, we will display the analyses of studies in separate forest plots. This will contribute to a demonstration and investigation of heterogeneity, even when the pooled estimate cannot be presented.

As an alternative option, we will employ a descriptive synthesis, grouping studies around common results (e.g. statistically significant positive impact on a given outcome), and where possible, also common risk of bias assessment results.

In both quantitative and descriptive syntheses, the comparison of interest will be of the singing intervention versus any included comparators (active and passive grouped together).

Investigation of heterogeneity and subgroup analysis

We will examine the heterogeneity of the included studies:

  1. Visually, e.g. using forest plots, scatter plots, or bubble plots;

  2. Statistically, using the I2 statistic.

If substantial heterogeneity is identified, we will report this and examine possible causes by conducting subgroup analyses, as specified below. The specific statistical tests or descriptive comparisons, or both, will be conducted based on the synthesis method for each outcome, as described above. Subgroup analyses will be conducted using study‐level variables.

We plan to perform the following subgroup analyses:

  1. Intervention types (e.g. categorised as leisure time versus training versus disease‐specific approach);

  2. Disease (diagnosis);

  3. Comparators.

Where permitted by the body of evidence, further exploratory subgroup analyses may be performed for disease type and severity, and intervention setting and type.

Equity‐related assessment

Given the breadth of study, intervention, and control types already considered in this review, we do not plan to perform a specific health inequity assessment. However, we will extract demographic information and perform exploratory analyses of potential social gradients, where permitted by the study report.

Sensitivity analysis

We plan to include the following sensitivity analyses. Specific methods for these analyses will be determined based on the methods selected for the primary analysis (described above):

  1. Intervention duration – to examine previously reported and hypothesised relationships between singing intervention duration and outcome effects [74];

  2. Risk of bias assessment – to examine greater intervention effects reported from studies with higher risk of bias [107];

  3. Intention‐to‐treat versus per‐protocol analysis;

  4. Disease severity;

  5. Study design (e.g. cluster‐randomisation, multiple group studies).

Certainty of the evidence assessment

We plan to assess the certainty of the evidence for the critical outcomes 1 to 3 (health‐related quality of life, dyspnoea/breathlessness, and functional exercise capacity), conducted according to the GRADE criteria [108], which consider five factors: risk of bias; inconsistency; indirectness; imprecision; and publication bias. Risk of bias will be evaluated based on the criteria detailed in Methods; Risk of bias assessment in included studies. The other four factors will be independently evaluated by the same four review authors (MK, SC, KH, MM) according to established GRADE criteria. Disagreements will be resolved through discussion between the four review authors. Based on these evaluations, the certainty of evidence for each outcome will be classified as: high, moderate, low, and very low. The summary of findings table will report the certainty of evidence of singing versus all comparator groups (active and passive) at the immediate post‐intervention time point for all critical outcomes.

The review authors will not assess the certainty of the evidence for outcomes that are based, in whole or in part, on studies in which they have been involved themselves. In these cases, another review author will assess the certainty of the evidence.

Consumer involvement

We will not directly involve external consumers in the review due to limited resources, but the author group represents an important range of consumers, including health professionals and experienced researchers from various disciplines.

An indirect involvement of consumers is reflected in the scope of the review, building directly on the growing public interest, illustrated by the worldwide diffusion of singing groups for people with chronic respiratory diseases, and the growing body of research in the field in which, e.g. participant perspectives have been incorporated into several qualitative and mixed‐methods studies [39, 40, 46, 48, 50, 51, 109]. Besides, the review will address the repeated request for building evidence‐based and motivating options within an increasingly personalised and targeted pulmonary rehabilitation model for the benefit of people with chronic respiratory diseases.

We included indirect consumer involvement in the development of the review protocol, in the definition of the outcomes of interest, and which, to a large extent, include perspectives from previous reviews [47, 68, 69]. We also included key components and perspectives from the previous developments of Core Outcome Sets (COS) for pulmonary rehabilitation, which were developed on the basis of direct and systematic consumer involvement [62, 63].

Supporting Information

Supplementary materials are available with the online version of this article: 10.1002/14651858.CD016265.

Supplementary materials are published alongside the article and contain additional data and information that support or enhance the article. Supplementary materials may not be subject to the same editorial scrutiny as the content of the article and Cochrane has not copyedited, typeset or proofread these materials. The material in these sections has been supplied by the author(s) for publication under a Licence for Publication and the author(s) are solely responsible for the material. Cochrane accordingly gives no representations or warranties of any kind in relation to, and accepts no liability for any reliance on or use of, such material.

Supplementary material 1 Search strategies

CD016265-SUP-01-searchStrategy.html (42.7KB, html)

New

Additional information

Acknowledgements

Cochrane Central Editorial Service and Cochrane Airways supported the authors in the development of this protocol.

The following people conducted the editorial process for this article:

  • Sign‐off Editor (final editorial decision): Anne E Holland, Monash University and Alfred Health;

  • Managing Editor (selected peer reviewers, provided editorial guidance to authors, edited the article): Leanne Jones, Central Editorial Service;

  • Editorial Assistant (conducted editorial policy checks, collated peer‐reviewer comments and supported the editorial team): Joshua Guinoo, Central Editorial Service;

  • Copy Editor (copy editing and production): Victoria Pennick, Cochrane Central Production Service;

  • Peer‐reviewers (provided comments and recommended an editorial decision): Ann Napier (patient and public review); Katharina da Silva Lopes, Cochrane Evidence Production and Methods Directorate (methods review); Jo Platt, Central Editorial Information Specialist (search review).

Contributions of authors

Authors: Mette Kaasgaard (MK), Stephen Clift (SC), Camilla H Nejstgaard (CN), Kirsten B Rasmussen (KR), Katarzyna Grebosz‐Haring (KH), Helene L Hartmeyer (HH), Arne Bathke (AB), Morten Hostrup (HM), J Matt McCrary (MM)

Contributions to the protocol

Initiation of protocol: MK

Conception of protocol and review: MK, HH, MM (the other authors provided important intellectual feedback)

Co‐ordination of the protocol: MK

Writing of the protocol: MK, MM, HH (the other authors provided important intellectual feedback for all sections)

Specific areas of contributions

Initial search strategy: MK, HH, MM, KBR

Detailed search strategy, including searching other resources: MK, HH, MM, CN, KR

Methodological comments: MK, MM, CN, AB, KR

Clinical comments: MK, MH

Intervention comments and rationale: MK, MM, SC, KH, MH

Statistical comments: AB, MM

Planned contributions for the review

Co‐ordinating the review: MK

Literature searches with support from the Cochrane Airways editorial team: MK, MM, SC, KH, KR

Retrieving papers: MK, KH, SC, MM, KR

Screening retrieved papers against eligibility criteria: MK, KH, SC, MM, KR

Appraising quality of papers: MK, KH, SC, MM

Extracting data from papers: MK, KH, SC, MM

Role as a third review author to resolve disagreements: CHN

Writing to study authors for additional information: MK, SC, MM

Managing data for the review: MK, KH, SC, MM

Entering data into RevMan: MK, KH, SC, MM

Analysing and interpreting data: all authors

Writing the review: MK, SC, KH, MM (the other authors will provide important intellectual feedback for all sections)

The review authors will not perform any selection, data extraction, risk of bias assessment, or certainty of the evidence assessment for studies in which they have been involved themselves. In these cases, the tasks will be handled by one of the other review authors related to the study.

Declarations of interest

Kaasgaard M: has been involved in the conduct, analysis, and publication of research on singing and respiratory diseases

Clift S: has been involved in the conduct, analysis, and publication of research on singing and respiratory diseases

Hansen Nejstgaard C: none known

Buch Rasmussen K: none known

Grebosz‐Haring K: none known

Hartmeyer HL: none known

Hostrup M: none known

Bathke A: none known

McCrary JM: none known

The review authors will not perform any selection, data extraction, risk of bias assessment, or certainty of the evidence assessment for studies in which they have been involved themselves. In these cases, the tasks will be handled by one of the other review authors related to the study.

Sources of support

Internal sources

  • New Source of support, Other

    No funding received for the protocol, nor for the review.

External sources

  • Sources of support, Other

    No funding received for the protocol, nor for the review.

Registration and protocol

Cochrane approved the proposal for this review in October 2024.

Data, code and other materials

Data sharing is not applicable to this article as it is a protocol, so no datasets were generated or analysed.

Notes

Published notes in RevMan are for editor use only. Authors should leave this section blank.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary material 1 Search strategies

CD016265-SUP-01-searchStrategy.html (42.7KB, html)

Data Availability Statement

Data sharing is not applicable to this article as it is a protocol, so no datasets were generated or analysed.

Articles from The Cochrane Database of Systematic Reviews are provided here courtesy of Wiley

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