Abstract

Optimal lung and respiratory function are critically important for patients living with significant congenital heart disease. Singing, which promotes efficient breathing mechanics, has shown benefits across multiple lung diseases and may similarly improve health and well-being in children who have undergone the Fontan operation. Trained singers commonly develop improved posture, respiratory muscle strength, and diaphragmatic control—benefits that may be particularly valuable for children with reduced exercise capacity following repeated sternotomies. Although extensively used in adults with asthma, cystic fibrosis, and chronic lung disease, singing-based therapy has not been formally studied in pediatric patients with Fontan physiology with complex congenital heart disease until 2024.

The Bienen School of Music and the Lurie Children’s Heart Center launched in 2024 a feasibility study demonstrating the impact of structured music and singing instruction in children and adolescents with Fontan Circulation, with manuscript preparation underway. We are expanding the population recognizing the central role in pulmonary health in significant congenital heart disease with repeat (2 or more) sternotomies and/or thoracotomies. The program incorporates guidance from experienced vocal instructors, exercise physiology, physical therapy, and nursing/physician pediatric cardiology-focused providers. The curriculum offers both in-person and virtual instruction sessions.

Play video


Hypothesis

Singing and breathing instruction will improve respiratory function, exercise capacity, quality of life, and overall well-being in children with complex congenital heart disease.

Primary Objective 

To determine whether structured singing and breathing instruction leads to measurable improvements in respiratory function and exercise capacity.

Secondary Objective 

  • Evaluate whether group singing improves quality of life and well-being.
  • Assess feasibility, acceptance, and adherence to a hybrid (in-person and virtual) singing curriculum designed by the Northwestern University Bienen School of Music for children at risk of cardiorespiratory complications.

Study Descriptives 

This study is recruiting children 7-14 years of age during the period with single ventricle circulation s/p surgical palliation or any other significant congenital or acquired heart disease with 2 or more sternotomies and/or thoracotomies. Children must be on a stable medical regimen 2 months before entry into the study and without surgery within 6 months before enrollment, be able to comply with spirometry and exercise assessments, and be willing to participate and able to complete age-adjusted questionnaires on quality of life (parent and child).  

References

Congenital Heart Disease Articles:

  1. Abdulkarim A, Shaji S, Elfituri M, et al. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol. Jun 27 2023;81(25):2434-2444. doi:10.1016/j.jacc.2023.04.036
  2. Alonso-Gonzalez R, Borgia F, Diller GP, et al. Abnormal lung function in adults with congenital heart disease: prevalence, relation to cardiac anatomy, and association with survival. Circulation. Feb 26 2013;127(8):882-90. doi:10.1161/circulationaha.112.126755
  3. d'Udekem Y, Iyengar AJ, Cochrane AD, et al. The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation. Sep 11 2007;116(11 Suppl):I157-64. doi:10.1161/CIRCULATIONAHA.106.676445
  4. Ginde S, Earing MG. When the Heart Is Not to Blame: Managing Lung Disease in Adult Congenital Heart Disease. Prog Cardiovasc Dis. Sep-Oct 2018;61(3-4):314-319. doi:10.1016/j.pcad.2018.07.019
  5. Ginde S, Bartz PJ, Hill GD, et al. Restrictive lung disease is an independent predictor of exercise intolerance in the adult with congenital heart disease. Congenit Heart Dis. May-Jun 2013;8(3):246-54. doi:10.1111/chd.12010
  6. Goldberg DJ, Shaddy RE, Ravishankar C, Rychik J. The failing Fontan: etiology, diagnosis and management. Expert Rev Cardiovasc Ther. Jun 2011;9(6):785-93. doi:10.1586/erc.11.75
  7. Grosch IB, Andresen B, Diep LM, Diseth TH, Moller T. Quality of life and emotional vulnerability in a national cohort of adolescents living with Fontan circulation. Cardiol Young. Jun 2022;32(6):874-882. doi:10.1017/S1047951121003188
  8. Goldenberg RB. Singing Lessons for Respiratory Health: A Literature Review. J Voice. Jan 2018;32(1):85-94. doi:10.1016/j.jvoice.2017.03.021Hawkins SM, Taylor AL, Sillau SH, Mitchell MB, Rausch CM. Restrictive lung function in pediatric patients with structural congenital heart disease. J Thorac Cardiovasc Surg. Jul 2014;148(1):207-11. doi:10.1016/j.jtcvs.2013.07.080
  9. Jone PN, Ivy DD, Hauck A, et al. Pulmonary Hypertension in Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circ Heart Fail. Jul 2023;16(7):e00080. doi:10.1161/hhf.0000000000000080
  10. Khairy P, Fernandes SM, Mayer JE, Jr., et al. Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation. Jan 1 2008;117(1):85-92. doi:10.1161/CIRCULATIONAHA.107.738559
  11. Marshall KH, D'Udekem Y, Sholler GF, et al. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. J Am Heart Assoc. Mar 17 2020;9(6):e014172. doi:10.1161/JAHA.119.014172
  12. Müller J, Ewert P, Hager A. Number of thoracotomies predicts impairment in lung function and exercise capacity in patients with congenital heart disease. J Cardiol. Jan 2018;71(1):88-92. doi:10.1016/j.jjcc.2017.05.005
  13. Neidenbach R, Freilinger S, Stöcker F, et al. Clinical aspects and targeted inspiratory muscle training in children and adolescents with Fontan circulation: a randomized controlled trial. Cardiovasc Diagn Ther. Feb 28 2023;13(1):11-24. doi:10.21037/cdt-22-308
  14. Opotowsky AR. Abnormal spirometry in congenital heart disease: where do we go from here? Circulation. Feb 26 2013;127(8):865-7. doi:10.1161/circulationaha.113.001004
  15. Sutherland N, Jones B, d'Udekem Y. Should We Recommend Exercise after the Fontan Procedure? Heart Lung Circ. Aug 2015;24(8):753-68. doi:10.1016/j.hlc.2015.03.005
  16. Wu FM, Opotowsky AR, Denhoff ER, et al. A Pilot Study of Inspiratory Muscle Training to Improve Exercise Capacity in Patients with Fontan Physiology. Semin Thorac Cardiovasc Surg. Winter 2018;30(4):462-469. doi:10.1053/j.semtcvs.2018.07.014

Music and Choir Articles:

  1. Bonilha AG, Onofre F, Vieira ML, Prado MY, Martinez JA. Effects of singing classes on pulmonary function and quality of life of COPD patients. Int J Chron Obstruct Pulmon Dis. 2009;4:1-8.
  2. Engen RL. The singer's breath: implications for treatment of persons with emphysema. J Music Ther. Spring 2005;42(1):20-48. doi:10.1093/jmt/42.1.20
  3. Fukuda Y. Breathing training for asthmatic children using music therapy and a survey on patient preference in the training methods. In: Laufer D CK, Ellis P ed. Music as a Human Resource: Drafts and Developments. Klön: Verlag Dohr; 1994:149-71.
  4. Ganzoni C, Arslani K, Pfister O et al.  Choir singing improves respiratory muscle strength and quality of life in patients with structural heart disease – HeartChoir:  A randomized clinical trial.  Swiss Med Wkly.  Sept 16 2020;150:w20346 doi:10.4414/smw.2020.20346
  5. Heck PS, Reinhardt W, Bischoff A, & Koelsch S.  The role of active music making in fostering resilience.  Frontiers in Neuroscience.  August 26 2025;(19) 2- 8.  doi.org/10.3389/fnins.2025.1629500.
  6. Irons JY, Petocz P, Kenny DT, Chang AB. Singing as an adjunct therapy for children and adults with cystic fibrosis. Cochrane Database Syst Rev. Jul 12 2019;7(7):CD008036. doi:10.1002/14651858.CD008036.pub5
  7. Irzaldy A, Wiyasihati SI, Purwanto B. Lung Vital Capacity of Choir Singers and Nonsingers: A Comparative Study. J Voice. Nov 2016;30(6):717-720. doi:10.1016/j.jvoice.2015.08.008
  8. Kenny DT, Faunce G. The impact of group singing on mood, coping, and perceived pain in chronic pain patients attending a multidisciplinary pain clinic. J Music Ther. Fall 2004;41(3):241-58. doi:10.1093/jmt/41.3.241
  9. Lewis A, Cave P, Stern M, et al. Singing for Lung Health-a systematic review of the literature and consensus statement. NPJ Prim Care Respir Med. Dec 1 2016;26:16080. doi:10.1038/npjpcrm.2016.80
  10. Lewis A, Philip KEJ, Lound A, Cave P, Russell J, Hopkinson NS. 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. Nov 2021;8(1)doi:10.1136/bmjresp-2021-000996
  11. Lipawen P. The effects of harmonica playing on lung function in asthmatic children. 2000
  12. Lord VM, Hume VJ, Kelly JL, et al. Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial. BMC Pulm Med. Nov 13 2012;12:69. doi:10.1186/1471-2466-12-69
  13. National Health Service. Carer centers and services: Sing For Your Life. Updated February 1, 2024. Accessed February 28, 2024. https://www.nhs.uk/services/service-directory/sing-for-your-life/N10497879
  14. Unwin M. The Effects of Group Singing on Mood. Psychology of Music. 2002;30(2):175-185. doi:10.1177/0305735602302004
  15. Wade L. A Comparison of the Effects of Vocal Exercises/Singing Versus Music-Assisted Relaxation on Peak Expiratory Flow Rates of Children with Asthma. Music Therapy Perspectives. 2002;20(1):31-37. doi:https://doi.org/10.1093/mtp/20.1.31
  16. Whitehead L, Arabiat RND, Foster M. Singing as an adjunct therapy for children and adults with cystic fibrosis: A Cochrane review summary. Int J Nurs Stud. Jun 2018;82:163-164. doi:10.1016/j.ijnurstu.2017.09.007