Pope Francis suffers new breathing attacks and undergoes two bronchoscopies

The 88-year-old pontiff is struggling to recover from pneumonia

A nun holds a picture of Pope Francis and a rosary as the faithful attend a Rosary prayer for the health of the pontiff at St Peter's Square in Vatican City on Monday. EPA

Pope Francis has suffered two new breathing attacks, requiring two separate bronchoscopies, the Vatican said, as the 88-year-old pontiff struggles to recover from pneumonia.

“Today, the Holy Father experienced two episodes of acute respiratory failure, caused by a significant accumulation of endobronchial mucus and consequent bronchospasm,” the Vatican said on Pope Francis's 18th day in hospital, the longest of his papacy.

In its usual evening update on Monday, the Holy See said the pope had resumed the use of an oxygen mask and noted that he was “alert, focused and co-operative”.

Doctors had extracted “copious” amounts of mucus from his lungs during the two bronchoscopies, in which a camera-tipped tube was sent down into his airways with a sucker at the tip to suction out fluid.

The Vatican said the mucus was the body's reaction to the original pneumonia infection and not a new infection, given laboratory tests did not indicate any new bacteria.

It added that Francis's prognosis remains “reserved”, an indication that doctors cannot predict the likely outcome of his condition.

The Argentine pope was admitted to Rome's Gemelli hospital on February 14 with bronchitis, which developed into pneumonia in both lungs, causing alarm around the globe.

Despite “slight” incremental improvements in the pope's condition last week, according to the Vatican, he suffered a setback on Friday with a bronchospasm that required him to use a “non-invasive mechanical ventilation”.

On Monday, with the two episodes of acute respiratory failure, the Vatican said the two separate bronchoscopies were performed in order to “aspirate abundant secretions”.

Acute respiratory failure, which can be life-threatening, occurs when the lungs cannot pass enough oxygen into the blood, or when carbon dioxide builds up in the body.

What is a bronchoscopy?

A bronchoscopy is a medical procedure that allows doctors to view the air passages using a small camera at the base of a flexible tube, while also taking tissue samples.

On Sunday evening, the Vatican had said the condition of the leader of the world's almost 1.4 billion Catholics was stable.

Francis, who has been pope since March 2013, had required the oxygen mask on Friday and Saturday, but not on Sunday, when he participated in mass and spent the rest of the day alternating rest with prayer.

Dr John Coleman, a pulmonary critical care doctor at Northwestern Medicine in Chicago, said the latest 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 non-invasive mechanical ventilation for a day and then did not need it any more.

The use of bronchoscopies reflects a worrying level of mucus and phlegm in the lungs, Dr 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 Dr Coleman, who is not involved in Francis' care.

The pope on Sunday received Italian Cardinal Pietro Parolin, the Vatican's secretary of state, and Edgar Pena Parra, a Venezuelan archbishop who is also a senior Vatican official.

The Jesuit is being treated in a special suite reserved for pontiffs on the 10th floor of the Gemelli, where the Vatican has said he has continued to work.

Francis, born Jorge Bergoglio, missed his traditional Angelus prayer for a third straight Sunday and the Vatican issued a written text instead.

In it, the pope thanked well-wishers for their prayers, saying: “I feel all your affection and closeness and, at this particular time, I feel as if I am 'carried' and supported by all God's people. Thank you all.”

Pontiff's path to recover could be long

As pilgrims and other well-wishers pray and leave offerings outside the hospital, medical experts, along with the Vatican itself, continue to warn that Pope Francis is not out of danger and the path to recovery could be long.

This hospital stay is the fourth of his nearly 12-year papacy.

In recent years, he has had surgery on his colon, a hernia operation and pain in his knee and hip that have caused him to rely on a wheelchair.

There has been speculation as to whether he might now resign, especially as his schedule has been packed with papal duties amid celebrations for the holy Jubilee year.

The Vatican has not released any photos or videos of Pope Francis since before he entered the hospital on February 14 with a complex lung infection. It has become the longest absence of his papacy.

He has said he would be open to following his predecessor, Benedict XVI – who in 2013 stepped down because of his physical and mental health – were he unable to fulfil his functions as pope.

However, before he was recently taken to hospital, he repeatedly had said it was not yet the time.