For more than a quarter of a century, high-frequency oscillatory ventilation (HFOV) has been a principal rescue modality in the management of paediatric acute respiratory distress syndrome [1]. Even though HFOV is used in children, its efficacy data are limited [[2], [3], [4]]. Two large adult trials, viz, High-Frequency Oscillation for Acute Respiratory Distress Syndrome (OSCAR) and High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome (OSCILLATE), tested the efficacy of HFOV in moderate to severe respiratory failure. The OSCILLATE study was stopped early because of increased mortality in the HFOV group [5], while the OSCAR study reported no difference in all-cause mortality between patients managed with HFOV and those managed with conventional mechanical ventilation [6] (see Table 1, Table 2).

The effects of HFOV are thought to depend on the timing of initiation. The use of HFOV in new-borns, within 24–48 h of admission, was at least as effective as conventional mechanical ventilation [7] whereas worse clinical outcomes were seen among children with acute respiratory failure [8}. Bateman ST et al. [9] found that, early HFOV was associated with a longer duration of mechanical ventilation and that the current approach to HFOV to be less convincing.

Regardless of such disheartening results, HFOV continues to be utilised in severe paediatric acute respiratory distress syndrome especially in resource limited settings where extracorporeal membrane oxygenation (ECMO) is not readily available. Here we share our experience comparing the outcomes among patients managed with early HFOV and those receiving late HFOV.