Background: High-frequency oscillatory ventilation(HFOV) delivers very small tidal volumes（<6ml/kg） at 3–15 Hz while maintaining a high mean airway pressure. HFOV is an ideal lung-protective ventilation mode, which is more and more often used in adults with the acute respiratory distress syndrome (ARDS) remaining hypoxemic during conventional mechanical ventilation. Objective: Though HFOV can improve oxygenation, the role of lung-protective doesn’t play good. It is uncertain whether the outcomes are well. The aim of this paper is to reach consensus on an approach to HFOV that we thought would maximize its lung protective virtues while maintaining acceptable gas exchange and safety. Content: In this review, we summarize the studies of HFOV and discuss the clinical experience using HFOV in adults in ARDS. Trend: While awaiting the results of these large RCTs, HFOV should be reserved for patients failing conventional ventilation-based lung protective strategies. Before initiating HFOV, we should consider the consequences of heavy sedation and paralysis, hemodynamic changes, barotrauma and excessive noise.