Pope Francis suffers new breathing crises, is back on noninvasive ventilation, Vatican says

Francis remained alert, oriented and cooperated with medical personnel. The prognosis remained guarded. Doctors didn't say if he remained in stable condition, though they referred to the crises in the past tense, suggesting they were over.

The crises were a new setback in what has become a more than two-week battle by the 88-year-old pope, who has chronic lung disease and had part of one lung removed, to overcome a complex respiratory infection.

Dr. John Coleman, a pulmonary critical care doctor at Northwestern Medicine in Chicago, said the episodes were more concerning than the last one on Friday, in which Francis had a coughing fit, inhaled some vomit that needed to be extracted and then was put on the noninvasive mechanical ventilation for a day and then didn't need it anymore.

The use of bronchoscopies reflects a worrying level of mucus and phlegm in the lungs, Coleman said. "The fact that they had to go in there and remove it manually is concerning, because it means that he is not clearing the secretions on his own," he said.

"He's taking little steps forward and then steps back," said Coleman, who is not involved in Francis' care.

In a late update, the Vatican said the episodes were caused by a "significant accumulation" of mucus in his lungs and bronchial spasms. "Copious secretions," were extracted during the bronchoscopies and the pope was put back on noninvasive mechanical ventilation, a mask that covers his nose and mouth and pumps oxygen into the lungs, the Vatican said.

Francis, who is not physically active, uses a wheelchair and is overweight, had been undergoing respiratory physiotherapy to try to improve his lung function. But the accumulation of the secretions in his lungs was a sign that he doesn't have the muscle tone to cough vigorously enough to expel the fluid.

The Vatican hasn't released any photos or videos of Francis since before he entered the hospital on Feb. 14 with a complex lung infection. This has become the longest absence of his 12-year papacy.

The Vatican has defended Francis' decision to recover in peace and out of the public eye. But on Monday one of Francis' closest friends at the Vatican, Archbishop Vincenzo Paglia, urged him to let his voice be heard, saying the world needs to hear it.

"We need men like him who are truly universal and not only one-sided," Paglia said, speaking after a press conference to launch the annual assembly of his Pontifical Academy for Life, the Vatican's bioethics academy, which has as this year's theme "The End of the World?"

Francis wrote a message to the assembly in which he lamented that international organizations are increasingly ineffective to combat the threats facing the world and are being undermined by "short-sighted attitudes concerned with protecting particular and national interests." It was dated Feb. 26 and signed "from Gemelli Polyclinic."

Doctors often use noninvasive ventilation to stave off an intubation, or the use of invasive mechanical ventilation. Francis has not been intubated during this hospitalization. It's not clear if he has provided any advance directives about the limits of his care if he declines or loses consciousness.

Catholic teaching holds that life must be defended from conception until natural death. It insists that chronically ill patients, including those in vegetative states, must receive "ordinary" care such as hydration and nutrition, but "extraordinary" or disproportionate care can be suspended if it is no longer beneficial or is only prolonging a precarious and painful life.

Francis articulated that to a meeting of Paglia's bioethics body in 2017, saying there was "no obligation to have recourse in all circumstances to every possible remedy." He added: "It thus makes possible a decision that is morally qualified as withdrawal of 'overzealous treatment.'"

Paglia, whose office helps articulate the Catholic Church's position on end-of-life care, said Francis is like any other Catholic and would follow church teaching if it came to that.

"Today the pope is giving us an extraordinary teaching on fragility," he added. "Today the pope, not through words but with his body, is reminding all of us, we elderly people to begin with, that we are all fragile and therefore we need to take care of each other."

Francis' 17-night hospitalization is by no means reaching the papal record that was set during St. John Paul II's numerous lengthy hospitalizations over a quarter century. The longest single hospitalization occurred in 1981, when John Paul spent 55 days in Gemelli for a minor operation and then a long infection that followed.