The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in an unprecedented shutdown in social and economic activity, with the cultural sector particularly severely affected. Restrictions on musical performances have arisen from a perception that there is a significantly higher risk of aerosol production from singing than speaking, based upon high-profile A c c e p t e d M a n u s c r i p texamples of clusters of COVID-19 following choral rehearsals. However, comparing aerosol generation from different types of vocalization, including singing, across a range of volumes is a rapidly evolving area of research. Here, we measured aerosols from singing, speaking and breathing from a large cohort of 25 professional singers in a range of musical genres in a zero-background environment, allowing unequivocal attribution of aerosol production to specific vocalizations. We do not assess the relative volumes at which people speak and sing. However, both showed steep increases in mass concentration with increase in loudness (spanning a factor of 20-30 across the dynamic range measured, p<0.001). At the quietest volume (50 to 60 dBA), neither singing (p=0.19) nor speaking (p=0.20) were significantly different to breathing. At the loudest volume (90 to 100 dBA), a statistically significant difference (p<0.001) was observed between singing and speaking, but with singing only generating a factor of between 1.5 and 3.4 more aerosol mass. Guidelines for musical performances should be based on the loudness and duration of the vocalization, the number of participants and the environment in which the activity occurs, rather than the type of vocalization.Mitigations such as the use of amplification and increased attention to ventilation should be employed where practicable.

Background Data on the long-term pulmonary sequelae in COVID-19 are lacking. Purpose To assess symptoms and functional impairment and residual pulmonary abnormalities on serial chest CT in COVID-19 survivors discharged from hospital at up to 1-year follow-up. Materials and Methods Adult patients with COVID-19 discharged between March 2020 and June 2020 were prospectively evaluated at 3 months and 1 year, through systematic assessment of symptoms, functional impairments, and thoracic CT as part of the PHENOTYPE study, an observational cohort study in COVID-19 survivors. Lung function testing was limited to participants with CT abnormalities and/or persistent breathlessness. All statistical analyses were performed using Graphpad PRISM Version 9.0 (86) for Mac, GraphPad Software, ( www.graphpad.com ); Bonferroni corrected p values are stated. Results Eighty participants (mean age, 59 ±13 years; 53 men) were assessed. Persistent breathlessness 37 (46%) and cough 17 (21%) were reported at outpatient review (median 97 days [IQR 86-121]). CT scans in 73 participants post-discharge (median 105 days [IQR 95-141]) revealed persistent abnormalities in 41/73 participants (56%), with ground-glass opacification (35/73 [48%]) and bands (27/73 [37%]) predominating. Unequivocal signs indicative of established fibrosis (i.e. volume loss +/- traction bronchiectasis) were present in 9/73 (12%) participants. Higher admission serum C-reactive protein (mg/L), fibrinogen (g/dl), urea (mmol/L) and creatinine (micromol/L), longer hospital stay (days), older age (years) and requirement for invasive ventilation were associated with CT abnormalities at 3-month follow-up. 32/41 (78%) of participants with abnormal 3-month follow-up CT underwent repeat imaging at a median of 364 (360-366) days, with 26/32 (81%) showing further radiological improvement (median 18% [IQR 10–40%]). Conclusion CT abnormalities were common at 3 months after COVID-19 but with signs of fibrosis in a minority. More severe acute disease was linked with CT abnormalities at 3 months. However, radiologic improvement was seen in the majority at 1-year follow-up. ClinicalTrials.gov Identifier: NCT04459351

Some patients hospitalized with acute COVID-19 suffer respiratory symptoms that persist for many months. We delineated the immune-proteomic landscape in the airway and peripheral blood of healthy controls and post-COVID-19 patients 3 to 6 months after hospital discharge. Post-COVID-19 patients showed abnormal airway (but not plasma) proteomes, with elevated concentration of proteins associated with apoptosis, tissue repair and epithelial injury versus healthy individuals. Increased numbers of cytotoxic lymphocytes were observed in individuals with greater airway dysfunction, while increased B cell numbers and altered monocyte subsets were associated with more widespread lung abnormalities. 1 year follow-up of some post-COVID-19 patients indicated that these abnormalities resolved over time. In summary, COVID-19 causes a prolonged change to the airway immune landscape in those with persistent lung disease, with evidence of cell death and tissue repair linked to ongoing activation of cytotoxic T cells.

The performing arts have been significantly restricted due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We report measurements of aerosol and droplet concentrations generated when playing woodwind and brass instruments and comparisons with breathing, speaking, and singing. These measurements were conducted in a room with zero number concentration aerosol background in the 0.5-20 μm diameter size range, allowing clear attribution of detected particles to specific activities. A total of 13 instruments were examined across 9 participants. Respirable particle number concentrations and size distributions for playing instruments are consistent with those from the participant when breathing, based on measurements with multiple participants playing the flute and piccolo as well as measurements across the entire cohort. Due to substantial interparticipant variability, we do not provide a comparative assessment of the aerosol generated by playing different instruments, instead considering only the variation in aerosol yield across all instruments studied. Both particle number and mass concentrations from playing instruments are lower than those from speaking and singing at high volume, and no large droplets >20 μm diameter are detected. Combined, these observations suggest that playing instruments generates less aerosol than speaking or singing at high volumes. Moreover, there is no difference between the aerosol concentrations generated by professional and amateur performers while breathing, speaking, or singing, suggesting conclusions for professional singers may also apply to amateurs.

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<p>The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in an unprecedented shutdown in social and economic activity with the cultural sector particularly severely affected. Restrictions on performance have arisen from a perception that there is a significantly higher risk of aerosol production from singing than speaking based upon high-profile examples of clusters of COVID-19 following choral rehearsals. However, no direct comparison of aerosol generation from singing and speaking has been reported. Here, we measure aerosols from singing, speaking and breathing in a zero-background environment, allowing unequivocal attribution of aerosol production to specific vocalisations. Speaking and singing show steep increases in mass concentration with increase in volume (spanning a factor of 20-30 across the dynamic range measured, <i>p</i><1×10^-5). At the quietest volume (50 to 60 dB), neither singing (<i>p</i>=0.19) or speaking (<i>p</i>=0.20) were significantly different to breathing. At the loudest volume (90 to 100 dB), a statistically significant difference (<i>p</i><1×10^-5) is observed between singing and speaking, but with singing only generating a factor of between 1.5 and 3.4 more aerosol mass. Guidelines should create recommendations based on the volume and duration of the vocalisation, the number of participants and the environment in which the activity occurs, rather than the type of vocalisation. Mitigations such as the use of amplification and increased attention to ventilation should be employed where practicable. </p>

Aerosol particles of respirable size are exhaled when individuals breathe, speak and sing and can transmit respiratory pathogens between infected and susceptible individuals. The COVID-19 pandemic has brought into focus the need to improve the quantification of the particle number and mass exhalation rates as one route to provide estimates of viral shedding and the potential risk of transmission of viruses. Most previous studies have reported the number and mass concentrations of aerosol particles in an exhaled plume. We provide a robust assessment of the absolute particle number and mass exhalation rates from measurements of minute ventilation using a non-invasive Vyntus Hans Rudolf mask kit with straps housing a rotating vane spirometer along with measurements of the exhaled particle number concentrations and size distributions. Specifically, we report comparisons of the number and mass exhalation rates for children (12–14 years old) and adults (19–72 years old) when breathing, speaking and singing, which indicate that child and adult cohorts generate similar amounts of aerosol when performing the same activity. Mass exhalation rates are typically 0.002–0.02 ng s −1 from breathing, 0.07–0.2 ng s −1 from speaking (at 70–80 dBA) and 0.1–0.7 ng s −1 from singing (at 70–80 dBA). The aerosol exhalation rate increases with increasing sound volume for both children and adults when both speaking and singing.

BackgroundNo currently approved intervention counteracts airway metaplasia and mucus hypersecretion of Chronic Bronchitis (CB) in COPD. Metered Cryospray (MCS) delivering liquid nitrogen (LN2) to the tracheobronchial airways ablates abnormal epithelium and facilitates healthy mucosal regeneration. The objective of this study was to evaluate the feasibility, efficacy and safety of MCS in CB.MethodsPatients with a FEV1, 30–80% of expected, taking optimal medication were recruited. Primary outcomes: feasibility – completion of treatments; efficacy – 3-month change in St George's Respiratory Questionnaire (SGRQ); safety – incidence of adverse events (AEs). Secondary outcomes: lung function, exercise capacity, additional patient-reported outcomes (PROs).Results35 patients, 19 male/16 female, aged 47–76 years, GOLD grade I (3), II (10) and III (22), underwent staggered LN2 treatments to the tracheobronchial tree.34 patients completed three treatments, each lasting 34·3±12·1 min, separated by 4–6 weeks: one withdrew after the first treatment. Approximately 1800 doses of MCS were delivered.Clinically meaningful improvements in PROs were observed at 3-months; ΔSGRQ −6·4 [95% CI −11.4, −1.3; p=0·01], COPD Assessment Test (CAT) −3·8 [95% CI −6.4, −1.3; p<0·01] and Leicester Cough Questionnaire (LCQ) 21·6 [95% CI 7.3, 35.9; p<0·01]. CAT changes were durable to 6-months (−3·4 [95% CI −5.9, −0.9; p=0·01]), SGRQ and LCQ to 9-months (−6·9 [95% CI −13.0, −0.9; p=0·03] and 13·4 [95% 2.1, 24.6; p=0·02], respectively).At 12-months, 14 serious AEs were recorded in 11 (31·4%) subjects, 6 moderate (43%) and 8 severe (57%). 9 were respiratory-related: 6 exacerbations of COPD, 2 pneumonias, and 1, increased coughing, recovered without sequelae. None were serious device or procedure-related AEs.ConclusionMCS is safe, feasible and associated with clinically meaningful improvements in multidimensional PROs.