<p>Pneumonia is common in patients with severe fever with thrombocytopenia syndrome (SFTS), and respiratory failure is one of its most severe complications. The aim of this study was to establish a nomogram for predicting respiratory failure development in SFTS patients with pneumonia. Data of demographics, comorbidities, clinical manifestations, laboratory parameters, complications, and outcomes of SFTS patients with pneumonia were collected. Independent predictors of respiratory failure development on multivariate logistic regression were used to construct the predictive model. Of the 167 SFTS patients with pneumonia we studied, 45 (26.9%) patients developed respiratory failure. Patients who developed respiratory failure had a higher incidence of invasive pulmonary aspergillosis, nosocomial infections, myocarditis, acute kidney injury (AKI) stage 2 or 3, rhabdomyolysis, shock, and systemic inflammatory response syndrome (SIRS). Among them, 35 patients died and all patients without respiratory failure survived. On multivariate regression analysis, neurological manifestations, nosocomial infections, AKI stage 2 or 3, SIRS, serum levels of albumin, and CKMB were proven to be independent predictors for respiratory failure development, which were adopted as parameters of the nomogram. The nomogram showed good calibration and discrimination, with an area under the receiver operating characteristic curve of 0.932 (95% CI 0.888–0.975). Decision curve analysis confirmed the clinical utility of the predictive model. Respiratory failure is associated with adverse outcomes including severe complications and death in SFTS patients with pneumonia. Clinicians could apply the nomogram to identify the high-risk pneumonic patients for developing respiratory failure.</p>