In the era of lung-protective ventilation strategies, high frequency oscillatory ventilation (HFOV) has attracted renewed interest and its use has dramatically increased in neonatal and pediatric intensive care units. HFOV is able to reduce ventilator-induced lung injury by limiting the incidence of volutrauma, atelectrauma, barotrauma and biotrauma. During HFOV, adequate oxygenation and ventilation is achieved by using low tidal volumes and small pressure swings at supraphysiologic frequencies. Unlike other high-frequency ventilation modes, HFOV has an active expiration phase. HFOV constitutes a safe and successful ventilation mode for managing pediatric patients with respiratory insufficiency refractory to optimized conventional mechanical ventilation and provides better results when initiated early. However, the elective use of HFOV requires further studies to identify its benefits over conventional modes of mechanical ventilation and to support its routine use as a first line therapy. In the present article, the Respiratory Working Group of the Spanish Society Pediatric Critical Care reviews the main issues in the pediatric application of HFOV. In addition, a general practical protocol and specific management strategies, as well as the monitoring, patient care and other special features of the use of HFOV in the pediatric setting, are discussed.