Respiratory failure in children continues to be a common and important indication for admission to intensive care units around the world. Acute respiratory distress syndrome represents the most severe form of respiratory failure in children and results from a variety of pulmonary and extra-pulmonary conditions. Despite important strides in our understanding and improved ventilator strategies of this very heterogeneous disease process, the mortality continues to be fairly high at 33%. High frequency oscillatory ventilation is an alternative form of mechanical ventilation with some attractive features in respect to attempting to improve gas exchange limiting ventilator induced lung injury. The objective of this review is to discuss the principles and the physiology of high frequency oscillatory ventilation, and its role in the management of children with respiratory failure. The adult literature will briefly be reviewed. The main emphasis on this review will be on the use of the "open lung" strategy in conditions that cause a reduction in functional residual capacity. In addition the "low volume" strategy that is useful in the setting of airleaks, such as pneumothorax and pneumomediastinum, will be briefly discussed.