ABSTRACT: OBJECTIVE: To report the immediate use of High-Frequency Oscillatory ventilation in an adult acute respiratory distress syndrome. DESIGN: Case report. SETTING: Intensive care unit at the Military Teaching Hospital of Toulon. PATIENT: A 64-yr-old Caucasian male who developed acute respiratory distress syndrome in the course of severe falciparum malaria. INTERVENTION: Initial use of HFO to minimise ventilator-induced lung injury. MEASUREMENT AND MAIN RESULTS: Rapid improvement of PaO2/fraction of inspired oxygen from 172 mmHg (NIV) to 310 mmHg with HFO. No ventilator-induced injury on CT scan after 5 days of invasive ventilation. CONCLUSION: In contrast with previous studies, we successfully used lung protective ventilation with HFO immediately. Further studies, with immediate, rather than rescue use of HFO ventilation, are needed.