Intensivists need to reevaluate high-frequency ventilation, whether their focus is adult or neonatal and pediatric disease. A recent consensus conference on adult mechanical ventilation recommended the goals of reversing atelectasis while avoiding overdistension. Both extremes of lung volume independently produce ventilator-induced lung injury. Currently these very treatment goals are being achieved in pediatric and neonatal critical care using high-frequency ventilation. The inflammatory process that fuels the acute respiratory distress syndrome can be moderated by achieving alveolar recruitment through the use of high-frequency oscillatory ventilation. Reassuring reports indicate that high-frequency ventilation does not increase the risk of adverse neurologic outcomes even in the very low birth weight infant. Combined therapies show benefit from the use of high-frequency oscillatory ventilation after surfactant and in the infant receiving pulmonary vasodilator therapy with nitric oxide. Complex transport theory is becoming clinically useful as the alveolar distension risks of high-frequency oscillatory ventilation are analyzed in terms of operating frequency and positive end-expiratory pressure levels. The emerging issues are those of timing of institution of high-frequency ventilation within the continuum of care now available.